A Virtual Ward to Reduce Readmissions After Hospital Discharge

A Virtual Ward to Reduce Readmissions After Hospital Discharge

The purpose of this study is to see whether a Virtual Ward reduces readmissions after hospital discharge.

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 the LACE index (see citation below for details) 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 physician availability and increased co-ordination of specialist, primary and home-based community care for several weeks after hospital discharge.

Inclusion Criteria:

• Discharge from medical service
• LACE score greater than or equal to 10
• Age greater than or equal or 18
• Resident in Toronto Central Local Health Integration Network catchment area
• Patient or designate able to speak English well enough for follow up telephone calls

Exclusion Criteria:

• Previously enrolled in study
• Discharged to a rehabilitation or complex continuing care facility