VHA Home HealthCare (VHA) is playing a leading role in launching the first-ever palliative remote care pathway for the Province of Ontario. The program enables nurses to monitor clients remotely virtually and communicate with their care team, supporting symptom management while clients live comfortably and safely at home.

The Remote Patient Monitoring: Palliative and Supportive Care Program is a North York Toronto Health Partners Ontario Health Team initiative led by partners VHA and North York General Hospital (NYGH) funded by the Ontario Ministry of Health. The pathway is targeted at patients of the NYGH Freeman Centre for the Advancement of Palliative Care and Edwin S.H. Leong Geriatric Supportive Care Outreach Program. 

“The goal is to help palliative clients live the best quality life that they can. Their care team may focus on things like pain reduction or mobility. There may be a number of goals that are important to clients and their families, and we can help by using remote care monitoring to enable them to report and track how they are doing,” said Alistair Forsyth, Chief Information Officer, VHA.

As Alistair notes, for a variety of client populations, including those experiencing single or multiple chronic co–morbidities, remote patient monitoring benefits clients and their families by providing them with readily available, condition-specific, and easy-to-use tools to manage their condition(s). Remote Patient Monitoring (RPM) has many other significant benefits including:

•  Improving data driven clinical decision making: RPM benefits providers by improving their clinical insight on a client’s status, in between office visits and offering them tools to inform proactive care delivery. With RPM, the provider sees how a client’s symptoms change over time, allowing the provider to identify trends or alter the client’s care plan accordingly.

• Reducing risk of hospital stay: RPM has demonstrated significant impact in reducing potentially avoidable Emergency Department use as well as reduced hospital admissions and readmissions. It enables care to be diverted from the Emergency Department and allows for earlier discharge with appropriate acute and chronic care monitoring, resulting in shorter lengths of stay in hospital.

• Improving access to care: RPM bridges the barrier of access by providing care to clients where they are, when they need it.  

• Optimizing engagement of caregiver team: RPM not only benefits clients, but their caregivers as well. Many RPM tools today involve the client’s caregivers by enabling their access to the client’s vital sign recordings and progress. With RPM, the caregiver can engage in and influence their loved one’s care and outcomes. It provides the caregiver with an extra layer of external support should a question arise, or an emergency occur. 

• Improving the clinician-client relationship: RPM benefits clinicians and clients by providing more opportunities for communication, thereby strengthening the client -provider relationship, and improving client satisfaction. It provides clients and families with the comfort of feeling that their provider is regularly checking on them. 

 Remote patient monitoring is also enabling enhanced collaboration across the care team and is having a positive impact on the clinician experience as well.

“I really like being part of the program,” said Rebecca Allotey, Remote Patient Monitoring RN (Registered Nurse), who is one of two nurses hired by VHA to exclusively work on the NYTHP RPM program. “We have flexibility and unlike working at the fast pace of bedside care, when we check-in with our clients remotely we are able to dig deeper and really understand their condition. As a result, clients are often more relaxed and comfortable with us as nurses and more willing to share sensitive information.” Rebecca has been working with VHA and NYTHP since January 2022.

Alongside the RPM nursing team as part of the program are primary nurses who visit the clients at home, Advance Practice Nurses, and physicians. This care team is designed to provide integrated supportive, palliative and end-of-life care for homebound clients with symptoms related to progressive, life-limiting, malignant & non-malignant illnesses (i.e., cardiac, respiratory, neurological, renal).

“The communication with the team has been great. When I’m monitoring clients, if I see that a symptom has worsened or a client expresses new pain or discomfort, I am able to escalate that to the visiting nurse, who can address their needs at home. We can also involve the primary physicians and their families to make sure the entire care team is involved in providing the client with timely care and support,” Rebecca added.

Ultimately, that seamless client experience is what it’s all about. The pilot is expected to run until July 2022, at which point it could become a model for other Ontario Health Teams across the province.

“The palliative program remote patient monitoring program is providing an extra layer of support to clients and caregivers,” said NYGH’s Amanda Mohamed, Project Manager of the RPM program. “They have the ability to contact a nurse and receive health resources in a matter of seconds. Remote patient monitoring at home allows clients and caregivers to feel more comfortable to leave the hospital and receive the care they need.”