Virtual wards are a model pioneered in England. They use the systems, staffing and daily routine of a hospital ward to provide case management to patients in the community but without the walls of the hospital. Patients who are admitted to the SETFHT Virtual Ward receive post-hospital discharge follow-up and interventions by a team of health care professional under the supervision of a physician. Interventions include daily phone calls to provide medical management in consultation with the family physician along with educating the patient on their specific chronic disease management and self-management. As well, there will be coordination of additional health care services as required within both the SETFHT team and to community supports. Electronic monitoring of vital signs may also be included for those with COPD, CHF or Diabetes. Target Population Virtual wards are an appropriate form of post-discharge care for patients who are considered to be at high risk of readmission, according to the LACE index. The patients in SETFHT's virtual ward are highly complex seniors - average age is 82.1 years old with an average LACE score of 12.5. The SETFHT Virtual Ward uses remote monitoring technology provided by Ontario Telemedicine Network (OTN). They are helping lay the groundwork for a new model of primary care in Ontario, one that ensures both quality and value and results in the best possible outcomes for patients. Evaluation data is being collected, and the patients are very happy with the care. Click here to view SETFHT's virtual ward patient brochure.
