Abstract
Background: To deliver the right care at the right time, this Nurse Practitioner-led team provides transitional short-term care for patients with respiratory infection and patients experiencing a current challenge related to chronic disease.
Approach: The Connected Care Hub (CCH) is a transitional care clinic led by Nurse Practitioners (NPs), which offers comprehensive virtual assessments, diagnosis, treatment, and close follow-up by NPs, nurses, and pharmacists, with connections to a variety of partners. Initially focused on the care of COVID-19 patients, this virtual model has since evolved into a hub managing short term care for patients with respiratory infection or chronic disease, both virtually and in-person. The CCH collaborates with home care providers, community pharmacies, specialists and primary care providers to better support patient needs and address gaps in care transitions. Virtual care has continued to be a core component, and informed by patient feedback: patients who have challenges with transportation and who are hesitant to seek care have benefited greatly, leading to a reduction in the intensity of care received.
The CCH works with patients to address social care needs such as financial challenges. For example, they source continuous glucose monitors for patients living with diabetes at no cost from pharmaceutical companies. Patients are also referred to partner programs that focus on addressing challenges related to social determinants of health such as food and housing insecurity, lack of finances, etc. This integration of health and social services, with a focus on finding solutions for unfunded resources, has been critical in the provision of universal health coverage.
With our hospital and community partners, our team’s boundaries are extending, enabling us to have Community Paramedicine in the patient’s home, virtual pharmacy on the phone, and even the ability to conduct joint visits both virtually and in the home with a variety of providers.
Results: Since inception, the CCH has provided transitional care to over 34,000 patients/carers with over 66,000 visits. As such, the team has smoothed transitions, particularly from hospital to home, and has prevented ED re-admissions. Conversely, we are seeing a small percentage of patients that need to be encouraged to go to the ED to receive the right care, thereby preventing a critical event at home, an intensive healthcare experience, and a worse outcome scenario. The team treats the whole person, spending time with the patient and carers to listen and understand the broader picture of their needs. In addition, patients receive enhanced education about their conditions, empowering them to gain a deeper understanding of their conditions and make informed decisions.
Implications: The CCH has learned about the value of partnerships in providing innovative solutions for community and home-based care. Our next steps include conducting a robust evaluation, working to facilitate primary care attachment, and learning more about additional populations to serve. We are also launching an advisory committee, including patients, to inform future directions.