From left, Kathleen Kirk and Beatrise Edelstein
In February 2021, Humber River Health (Humber) implemented a Long-Term Care (LTC) Remote Monitoring initiative in partnership with seven LTC Homes in Northwestern Toronto, scaled to two more LTCs in January 2022, and continues to grow. This program uses Practical Routine Elder Variants Indicate Early Warning for Emergency Department (PREVIEW-ED©), an observation-based clinical deterioration tool, and LTC+, an integrated team of healthcare professionals, to detect early signs of health deterioration in LTC residents and facilitate early intervention.
This initiative promotes an integrated, upstream approach to care through an innovative partnership between the hospital and LTC homes, reducing the number of emergency department (ED) visits and hospital admissions, which are key priorities for the Northwestern Toronto (NWT) Ontario Health Team (OHT).
On average, approximately 1,000 LTC residents per year visit the ED at Humber, with approximately 50 percent being admitted. By minimizing these occurrences, Humber's LTC Remote Monitoring initiative is improving resident care, optimizing patient outcomes, reducing healthcare system burden and costs, and boosting staff capacity.
Connecting Care: How Humber, LTCs, and Community Care Work Together
LTC+ aims to re-imagine access to care and is committed to expediting the care of LTC residents close to or in their homes. The program focuses on putting the resident first by streamlining access to community and hospital services that previously would have required transfer to the ED.
LTC+ is operated by nurse navigators who offer general advice and assistance in navigating services at Humber and in the community. Nurse navigators also facilitate urgent virtual consults between LTC physicians and a General Internal Medicine (GIM) Physician or Geriatrician to support timely access to care. To further ensure residents receive the care they need when needed, a Nurse Led Outreach Team (NLOT) is involved to provide urgent mobile care.
The program uses technology to deliver these services and creates stronger integration between LTC homes and the health care system more broadly. An electronic version of the PREVIEW-ED tool can be embedded within Point Click Care and includes tracking and reports. The tools and digital components ensure appropriate actions are completed in a timely manner at the LTC to avoid ED visits.
Improved Outcomes and Successes
Humber has seen significant outcomes and successes with this program. In March 2023, the program was expanded and launched new pathways in diagnostic imaging (DI) and transportation support for LTC residents, both supported by new funding from the Government of Ontario.
As a result of these expansions, between March and August 2023 Humber successfully diverted 139 ED visits from LTC homes and 99 patients were transferred to and from Humber via non-urgent transport. Furthermore, 154 consultations with nurse navigators were performed for DI needs.
LTC Remote Monitoring has also facilitated improved care coordination and increased knowledge and awareness of available resources among LTC staff. A provider experience survey revealed that 85.7 percent of LTC staff who interact with the program indicated improved ability to identify early health decline, 85 percent noted it has fostered their assessment skills, and 85 percent said that it has enhanced team communication related to changes in residents' health status.
These successes are the result of the collaborative approach among Humber's partners in the LTC sector and the Humber team. The leadership of Beatrise Edelstein in establishing, operating and evaluating this initiative has ensured that it is sustainable and meets the needs of both LTC residents and care providers. Kathleen Kirk, Clinical Manager, has been instrumental in leading and supporting collaboration with LTC homes and physicians, as well as overseeing the program's execution and evaluation. Humber's team of knowledgeable nurse navigators help bring the program to life and ensures its ongoing success.
Within this innovative initiative, the contributions of Beatrise Edelstein and Kathleen Kirk stand out as prime examples of leadership and dedication in the healthcare sector. Their achievements highlight the crucial role of female leadership in driving innovation and improvement in healthcare. Their work exemplifies how determined, skilled women can lead complex projects that make a significant difference in the lives of vulnerable populations. This project showcases the exceptional capabilities of women in healthcare and their ability to lead with compassion, innovation, and effectiveness to advance patient care.
Expanding Accessibility and Equitable Care
The program is guided by an overarching philosophy of supporting LTC residents in their homes and increasing access to equitable care. Many factors influence patient access to equitable care, and those variables are often compounded and more complex for seniors.
Two common barriers to care for seniors in LTC are cost and transportation. A standardized, free-to-access service is not currently in place to provide non-emergency transportation for LTC residents. In response to this, Humber, alongside program partners and with the support of the Government of Ontario, is piloting a service that provides free transportation to residents who need to receive care outside of their LTC home.
Humber is the only acute hospital in the Greater Toronto Area that has a robust LTC+ hub that integrates a clinical deterioration tool (PREVIEW-ED) with LTC+ and its numerous pathways, and that is supported by NLOT and in-hospital nurse navigators. As Humber looks ahead, their focus is on continuing to expand and build upon the program, delivering care where it matters most – closer to home. They are eager to share their insights with other hospitals and healthcare providers as they continue to light new ways in healthcare.