Dedicated specifically to patients with certain chronic diseases – type 2 diabetes, heart failure, chronic obstructive pulmonary disease (MPOC) and osteomyelitis, for example – the improved remote monitoring program for 2022 aims since 2022 to support patients following hospitalization, a question of ensuring a continuum of distance care while promoting people’s autonomy.
“We know that when the patient goes home after his leave, it is the period which is the most critical, after hospitalization, for returns to emergencies, readmissions, anxiety. It will also help in self -management [de la maladie chronique]the patient becomes a little more independent, ”argues Gasline Ternier, clinical director of integrated and ambulatory care.
Lighten the pressure
The concept, developed according to it to, among other things, provide “in the right place and good time” care and thus lighten “pressure” on emergencies, two axes prioritized by Health Ontario, allows patients to have access to large post-hospitalization support for a period of six months, in stages.
“It’s really to try to avoid readmissions. […] It was 24/7 during the first four weeks after the patient’s leave as support in the community. If there are questions, concerns, you have access to talking to nurses, there are paramedics too who make visits [dans les 12 heures suivant la demande] according to needs and acuity [des soins] of the patient, ”notes Ms. Ternier.
Since the establishment of this program, the rate of emergency visits for this type of user has increased from 39 % to just under 10 %, while the readmissions to the hospital has dropped by more than half, going from 23 % to 11 %.
“This is still something,” said the manager proudly, adding some 800 interactions of coaching Health per week with patients “to equip them, strengthen their autonomy at home, improve the experience with transition points”.
Several partners
Imagined at Montfort Hospital, the program was developed in partnership with the community paramedics of Ottawa and the United Prestcott and Russell Counties, Home Health Ontario and the Ontario Archipel health team. The Hawkesbury hospital as well as the Queensway-Carleton hospital also collaborated there.
“It’s a big win For us but also for patients, because no one who had their leave wants to return to the hospital right away, ”says Ms. Ternier.
Only in Montfort, 1340 patients benefited from the new model in the space of three years.
The improved remote monitoring program of care was also awarded earlier this year, being recognized by the organization of health standards (HSO) and Approval Canada as an exemplary health care practice.
“This recognition famous not only an exemplary initiative, but above all a collaborative, daring and innovative approach which transforms the experience of patients,” said Dominic Giroux, Chairman and CEO of Montfort Hospital.
Only Ontario residents [Ottawa et l’Est ontarien] are eligible for this program, Home Health Ontario and paramedics do not serving Quebec patients.
Future
In an era where the shortage of workforce is strongly raised, patient responsibility is more advocated and the vice is tightening fairly on the health network-particularly emergencies-due in particular to the aging of the population, this principle based on self-management is a good asset, believe the authorities. There is however a balance to have, specifies the manager.
“It’s always difficult with a chronic disease to self -help because it can be overwhelming for a patient to try to manage everything, to control everything. But this program, definitively, allows for a strengthening of the autonomy of patients with all the tools and resources that are available to them, explains Ms. Ternier. It also reassures the user to know that if he never feels good, he can call a nurse, have a visit to the paramedics. It is a process that gives the person a little more confidence. ”
This program is one of the ways of the future, it believes it.
“It may be that I am biased, because it’s my team, but I think it’s innovative and the pandemic has had a grain of salt in there. We were able to get out of our comfort zones [dans le milieu hospitalier] To really explore intercollaborative programs. It is a program that really meets the needs of patients and ensures continuity, accessibility of care, which is safe and reliable.