Tim’s wound was gaping when I saw it. As Tim’s primary nurse, I helped settle him into his room after he arrived at the southern Ontario hospital via air ambulance. Tim had undergone open-heart surgery the month prior and had left the unit more than three weeks earlier with a well-aligned, healthy-looking breastbone incision.
Although Tim was stoic, that same incision was now gaping and oozing. I asked myself what could have led to this. Was the education provided during his post-operative care insufficient? Was the discharge teaching overwhelming or unclear? Was Tim unable to see his family physician or specialist doctors at the recommended times for follow-up? Living in a remote Northern Ontario community, Tim’s access to health care was not ideal. I could not help but wonder how such complications could have been prevented.
In Canada, one in 11 patients is readmitted within 30 days of being discharged from hospital, costing the country $2.3 billion a year. Furthermore, the risk of readmission is 14 per cent higher for patients in poorer neighbourhoods than those in more affluent communities. Tim’s story is a stark reminder that as the health-care system evolves, those at the margins are at risk of being neglected. Innovation must drive system evolution and design to ensure equitable health-care delivery.
One way to decrease readmissions is through virtual care, in which patients interact with one or more health-care providers via videoconferencing, telephone, web-based tools or secure messaging. It strengthens patient engagement, enhances ease of access and convenience, and improves clinical outcomes – all while reducing costs. Hence, it aligns with a value-based model of care and can improve the patient and health-care provider experience.
Canada was an early pioneer in virtual care. A. Maxwell House utilized telephone consultations to follow up with his patients in the 1970s. While the rate of development of virtual-care technologies has varied across provinces since then, the demand and subsequent deployment of digital health solutions have grown steadily. For instance, in 2018, just 3 per cent of Canadians indicated they had used synchronous video consultations, while 6 per cent had used email or messaging to consult with their regular doctor. COVID-19 exponentially increased the need for virtual consultations and follow-ups following discharge. A recent survey showed that Canadians expressed the desire to use email (63 per cent), text messaging (58 per cent) or video (44 per cent) to communicate with their regular doctor.
Ontario Telemedicine Network (OTN) was launched in 2006 to harness the potential of virtual care in filling gaps in health-care delivery. It was designed to be rolled out in phases: initially through OTN virtual sites in rural and remote Ontario, then home visits through OTNinvite. The government of Ontario, through the OTN, has recommended using either of two platforms for virtual follow up: eVisit by Novari Health or VirtualCare by ThinkResearch, both funded by the province.
Virtual follow-up has not been widely adopted in Canada yet.
Even so, virtual follow-up has not been widely adopted in Canada yet. There are few centres, however, that have implemented this framework and could serve as examples for others.
In 2019, the University Health Network started “Integrated Care” programs for discharged thoracic, cardiovascular and vascular surgery patients. St. Joseph’s Health System developed an evidence-based integrated care model with excellent results. Each program involves one digital patient record, one care team and one 24/7 phone line for patients and their caregivers. This telehealth program improved patient self-management and satisfaction, and decreased visits to the emergency department as well as hospital readmissions.
Recently, the Ottawa Hospital used a similar framework for its pilot project to optimize “Virtual Recovery After Surgery.” Depending on surgery type, some patients discharged home monitor their blood pressure, oxygen levels, weight and temperature via an app twice daily. In addition, they can connect virtually with their post-surgical care team for up to two weeks following surgery.
Telehealth and virtual follow-up are untapped resources with immense potential to address bottlenecks and pressures in the health-care delivery system. For example, several multinational studies have shown significant reductions in all-cause readmission rates, with a meta-analysis showing a 73 per cent relative reduction in three years. One significant implication is the freeing of hospital beds that would otherwise have been occupied. Furthermore, it conserves human health resources, ensuring that low-risk follow-up consults are carried out quickly and more frequently.
Federal and provincial governments can facilitate the widespread, tangible gains by standardizing policy and adapting virtual care to local contexts. Additionally, there must be consistency in billing, available services, service providers and infrastructure.
Critics have voiced concerns about virtual care’s potential to worsen existing health inequities. Currently, Ontarians in rural, remote, Northern and Indigenous communities lack reliable broadband internet and adequate bandwidth compared to urban centres. About 1.7 million Ontarians, 12 per cent, live in communities without access to minimum internet services, limiting their access to virtual care. To prevent this, Ontario must build on its 2019 broadband and cellular action plan to bridge the divide in broadband availability between rural and urban communities. In addition, priority must be given to underserved communities to ensure equitable access.
Stories such as Tim’s must not be allowed to happen. All stakeholders must fully resolve to ensure that no Canadian is left behind. If we genuinely care, we will ensure that all discharged patients stay healthy, no matter where they live or what ails them.
Once established, these programs should be expanded beyond post-surgical patients nationally to ensure all patients with readmission-prone conditions, such as heart failure, heart attacks and abnormal heart rhythm, are covered. Similarly, virtual follow-up interventions have the potential to snowball into regional care strategies, extending beyond large tertiary hospitals to smaller peripheral community hospitals and, subsequently, homes, empowering patients to contribute to the process of shared decision-making.
Reducing readmission rates through such strategies are specific ways for health-care stakeholders to prove to patients that they are committed to their well-being.
It is because we care that we do not want you to return.