Grant: Partnerships for Health System Improvement (PHSI)

We will conduct a pragmatic, randomized controlled trial to evaluate a new model of care for high-risk medical patients after discharge from hospital. This new model of care has two key elements. First, we will use a tool developed and validated by members of our research team to identify patients who are at high risk of readmission or death after hospital discharge. These patients will be randomized to either the Virtual Ward or usual care on the day of discharge. Although patients being cared for in the Virtual Ward will reside at home, they will benefit from a hospital-like interdisciplinary team, a shared set of notes, a single point of contact, round-the-clock availability and increased co-ordination of specialist, primary and home-based community care for several weeks after hospital discharge. Over 1500 patients will be included in our study. We hypothesize that the Virtual Ward will reduce readmissions by at least one-third. We will also be studying whether the Virtual Ward reduces emergency department visits, nursing home admissions and deaths. The Virtual Ward has been developed collaboratively by several acute care hospitals, an ambulatory care hospital and the Toronto Central Community Care Access Centre, with input from the Toronto Central Local Health Integration Network and the Ontario Ministry of Health and Long-Term Care. If we can demonstrate that the Virtual Ward is a better way to care for high-risk patients after hospital discharge, we believe hospitals across Canada will move quickly to implement Virtual Wards to better serve their patients.