Photo caption: A manager at Montfort Hospital demonstrates the remote monitoring application to a patient.
By: Laurence Paradis, Ann Salvador and Nazila Sattari
Patients with chronic illnesses or designated as Alternative Level of Care (ALC) who no longer require acute hospital care, can now return home sooner to continue their recovery safely. Through an Enhanced Remote Care Monitoring (ERCM) Program, these patients receive 24/7 support to ease the transition from hospital to home during the first four weeks post-discharge, and for up to six months.
The program has improved the experience of patients and caregivers by providing comprehensive support for the transition from hospital to home. It also promotes self-management of chronic conditions to increase independence and quality of life. In addition, the program offers timely, accessible and patient-centered care to help prevent unnecessary emergency visits and hospitalizations.
At Hôpital Montfort, between January 2022 and March 2025, 1,340 patients benefited from the program.
- Emergency room visits decreased by 75%, and hospital readmissions by 83%, compared with prior to the program
- 800+ health coaching interactions by staff via telemonitoring
- Patients demonstrated better self-management of their health and increased satisfaction with their hospital stay
The program has also improved system efficiency and value, while strengthening integration across primary, acute, home and community care. It has enhanced care coordination, addressed health equity and barriers, and supported team-based care by building provider trust and collaboration.
A collaboration between Hôpital Montfort, Ontario Health at Home, the Ottawa and Prescott-Russell Community Paramedics, with support from the Archipel Ontario Health Team, the program has since expanded to include the Queensway Carleton Hospital and the Hawkesbury and District General Hospital.
Patients with chronic illnesses, such as heart failure, chronic obstructive pulmonary disease, diabetes (type I&II), cellulitis, osteomyelitis, and other profiles such as frail elderly, can benefit from the ERCM program. These patients must live in Ontario, specifically in Ottawa, the United Counties of Prescott-Russell, Stormont, Dundas or Glengarry. The care team includes Ontario Health at Home (telemonitoring and rapid response nurses), local community paramedicine teams available overnight and for escalation support during the day, and Hôpital Montfort, which acts as the referral source and offers clinical support through chronic disease and diabetes clinics, as well as BSO nurse consultations. Patients are remotely monitored through a digital platform featuring clinical pathways, daily assessments, educational content, and biometric devices (e.g., blood pressure monitor, oximeter, scale).
This initiative highlights how Montfort and its partners are modernizing traditional care models to better meet patient’s needs at the right time and in the right place, helping prevent unnecessary hospital stays. It also demonstrates integrated care in action, breaking down silos between acute care and community services, and ensuring continuity of care beyond hospital walls.
The program has been running for three years, with outcomes that affirm the value of integrated care.
This innovative care model has recently been recognized as a best practice by the Health Standards Organization (HSO) and Accreditation Canada. This distinction is a testament to the excellence of the program, which is designed to support patients during the critical days following hospital discharge.
With this program, Montfort once again confirms its role as a leader in the development of modern and sustainable care solutions and reaffirms its commitment to offer exemplary person and community-centered care.