Danielle Kilby-Lechman, the manager of the RCM program, talks to Toronto Grace contributing writer Gerry Condotta about how the program evolved, its relationship with other Ontario Health Teams (OHT), and why it has been successful in reducing alternate level of care (ALC) days.
Jake Tran, President & CEO (Left) and Danielle Kilby-Lechman, Manager of RCM (Right)
When was the RCM program officially launched? Were you a part of it from the beginning?
Danielle: The RCM program began in 2019 with two clients. At the time, our partner, GRTHealth, a technology provider with an integrated service-delivery platform, was installing the devices that help monitor patients in the home, such as sensors, medication dispensing machines, and pendants. The referrals were being managed by our admissions coordinator at the Toronto Grace, and the program was overseen by one of our doctors. When I was hired in July 2021, the program had increased its client base to one hundred.
——
Were you hired as a manager?
Danielle: No, I was hired as a social worker in a client-facing role. So, for example, when a patient left the hospital, I worked with transitions, helping patients re-integrate back to the community. Before I became the manager, I was given the role of RCM program coordinator.
——
How did you become the RCM program coordinator?
Danielle: It became apparent to me after I had been working in the RCM program for a while that there wasn’t a great deal of knowledge about the RCM program and its services in acute care hospitals and the community. Not enough healthcare staff or healthcare providers knew about the program. I came to the Toronto Grace from an acute care hospital where I worked as a social worker, so I had a lot of knowledge on how acute care hospitals function. One of the important parts of the job for a social worker in a hospital is referrals. Social workers are the ones who refer patients to community supports. Over time, I had built relationships — a network. I had connections with acute care hospitals and social service agencies. I knew healthcare providers that I could present knowledge about our RCM program to … so I just reached out. It was at this point that I became the RCM program coordinator.
——
Can I assume you were no longer in a social worker role?
Danielle: Well … no. At the time, the RCM program had a smaller client base than it does today, so I was working as a social worker while at the same time also reaching out to my network by way of a lot of presentations. I provided social workers and discharge planners with knowledge about our RCM program and how it functioned. We managed to establish a good working relationship with a well-known hospital, and so our profile (mine and the Toronto Grace’s) became known. When that happened, it became easier to approach other hospitals. This was instrumental in helping us build a more robust RCM program to address the transitional healthcare gaps.
——
When did you officially become the manager of the RCM program?
Danielle: In February 2022. At that time, I had three staff on my team. I’m happy to say they are still with me — we have a 100 percent employee retention rate. I’m very proud of that.
——
How many staff do you have on your team now?
Danielle: Well, because we have been consistently developing the RCM program, we continue to hire more staff. Currently, — and this number will change — we employ thirty-nine people. I just want to take a moment to say that the RCM team are very dedicated and amazing; all of them go above and beyond and exceed expectations.
——
Let’s talk about the team. Can you describe the various roles within the team?
Danielle: Sure. There are Intake & Access Specialists — they process referrals, communicate with referrers, and provide support with admin tasks, as needed. They essentially manage the flow of the referrals. Then we have our Client Service Representatives. They manage the 24/7 call centre. The Allied Health team has transitional care coordinators who provide support with RCM+ (the clinical extension of the program): an occupational therapist (OT), a physiotherapist (PT), and a social worker (SW). I have two program coordinators who support me with day-to-day operations and give presentations to community partners about the RCM program. There is a nurse practitioner (NP) — she has an NP-led clinic and sees our unattached RCM clients. She also supports the Allied Health team. We have admin assistants providing support with general admin tasks. There are Field Technicians. They facilitate the installation of the devices in Toronto. We mail pendants to clients who live outside of Toronto, or we have the hub model. Finally, there’s one more staff member … me: the program manager. That makes thirty-nine staff managing a total of 8,875 active RCM clients — and that number is growing.
——
That is impressive — you have gone from one hundred active RCM patients In July 2021, when you were hired, to over eight thousand five hundred today! Can you clarify the function of the pendent and what you call hubs?
Danielle: Pendants help us monitor patients in the home. Pendants also help patients communicate with healthcare providers. We have a working relationship with different hospitals, and the hospitals serve as hubs. The RCM program has 20+ hubs —different hospitals have the pendants on site and are able to give them to patients before they leave hospital. Hospital staff (primarily social workers and discharge planners) are trained by the RCM team on how to educate patients/families on the use of the pendant. The RCM team then completes a wellness check with the patient forty-eight-hours after they are discharged. We know that patients are most vulnerable/at-risk for an emergency department (ED) “bounce back,” in the 24–48 hours post-discharge. This is because formal supports can take time to be arranged, and things can fall through the cracks. With hospitals serving as hubs, the wait time for installation of RCM devices is removed. This helps ensure a smooth discharge plan since patients are monitored as soon as they leave the hospital. The hub model also allows for scalability, the expansion of the program. The hubs are all across Ontario.
——
Danielle, can you take us through what happens at your call centre … say with a referral?
Danielle: Sure. A referral comes into our Intake & Access Specialist team at the Toronto Grace. The team reviews the referral for eligibility; they then email the referrer back, confirming it has been received. A pendant can have three different capabilities: falls detection, SOS button, and wandering. When a pendant is requested, it is specified whether it’s for one, two, or all three capabilities. In Toronto, our field technicians install the devices that monitor the client’s movement. Sensors are installed to monitor activity levels. If after a period of time no movement is detected, an alert is generated. This prevents clients who end up falling from lying on the floor for hours. Sensors are also placed on refrigerator doors. If the client doesn’t open the refrigerator within a certain period of time, an alert is generated. Some clients do not require a pendant and may only need a medication dispensing machine. If that’s the case, one of those is installed by one of our field technicians. If the client is not keeping up with their medications, the machine sends us an alert. The medication machine works like the pendant.
——
Really …sensors on a refrigerator door?
Danielle: Yes, we put sensors above doorways and in all the places that will deliver optimum monitoring of the home … even the refrigerator. Monitoring the refrigerator gives us insight into the psychological/social elements of someone’s life. If we’re getting an alert that the refrigerator door has not been opened, then clearly there are issues with not eating. We can look into that and from there we can escalate.
——
You’ve explained what happens at the call centre when a referral is sent, and thank you for that. What happens when an alert is generated? What happens at the call centre in that particular instance? Also, you said, “from there we can escalate.” How does that work?
Danielle: When an alert comes into the call centre, it appears on a dashboard that is monitored 24/7 by call centre staff. Our team then responds and escalates the incident to the appropriate party (e.g., family, 911, etc.). In many cases, our call centre staff are able to assist the client without involving EMS. Avoiding 911 calls is a goal of the program. For example, if a client is wandering, we will contact the family or other caregiver. Sometimes, a client will activate their pendant to express concerns about food security or other activities of daily living. We can escalate these non-emergency issues to other service providers, who can then follow up and provide an intervention (e.g., escalating to Home and Community Care Support Services (HCCSS). After an alert is resolved, the incident is thoroughly documented, and the notes are added to the client’s record.
——
Jake Tran, the CEO and president of the Toronto Grace Health Centre, has stated that the Toronto Grace has been invited to work with several OHTs and that you provide them with your RCM program data to help them deliver the appropriate care for their patients in their communities. What is the data you’re sharing? Can you elaborate?
Danielle: We really have established ourselves with the RCM program in Toronto and the GTA, but there are certain healthcare needs in rural communities that haven’t been met and are causing high ALC rates. So, we wanted to reach out to those more northern and rural communities to see how we can help. For example, Jake and I gave a presentation on our RCM program to the OHTs in North Bay and Thunder Bay. I think Jake was referring to an answer he gave in response to a question about how we developed the program — I think he was asked about how we use the data from the alerts to inform a medical intervention?
——
So, the data from the technology helps you to provide the right care at the right time?
Danielle: In my experience, technology can go only so far. We decided that we needed a more robust, holistic intervention. That’s why we added the clinical component to the program. Our OT, PT, SW, and NP. There needed to be some way of combining the data from the alerts with the clinical piece— we wanted to use the data to inform our clinical interventions. This would help us be more pro-active, more preventative. We could catch a client’s decline earlier, get an Allied Health team member involved, work the client’s resources, and provide the appropriate care at the right time so they don’t end-up in the ED.
——
How were you able to accomplish this balance between technology and a clinical intervention?
Danielle: It developed in stages; we built out the model internally first with our own Allied Health team and our own clinical interventions. This knowledge allows us now to scale and spread the program. We are now able to leverage existing resources. Instead of using our own clinical team, we’ll work with teams from other hospitals, which often provide home support. We developed the RCM program, and since then we have made sure the model is adaptable. We go to the OHTs in communities like Thunder Bay or North Bay, and we show them our program. They can adapt it to fit their community. The program is structured in a way that they can decide what aspects they can use — they can tailor the program to their needs. The rural communities were a huge focus for the Toronto Grace’s RCM program this year because these communities have very limited resources, very limited personal support workers (PSWs).
——
If they have limited resources, how can your RCM program help them?
Danielle: This relates back to using data from alerts— technology — to inform. For example, medications. In a lot of home care services, our people go into the home to provide medication reminders or medications assistance. If a client has a medications dispensing machine and we see that they are adhering to their medication dosage, then we can loop that information back to community services. This could provide us an opportunity to cut back the nursing or PSW support and reallocate the nurse or PSW to someone who truly needs it. In other words, if things are okay with that client, we can save money by scaling back PSWs and other community care providers. If things aren’t okay, we can adjust to increase the care being provided. The ability to be able to adjust accordingly helps to save money. We are not only addressing the issue of reducing ALC rates by ensuring that our clients don’t readmit, we also have an eye on the dollars and cents. What is the use of having a program if it’s not structured to operate efficiently? I think other OHTs whose resources are limited can benefit from adapting this strategy.
I just thought of something that also speaks to the efficiency of our RCM team. I stated earlier that our field technicians go into the home to set up the required devices to monitor clients. Those field technicians are at ground level; in other words, they actually see the clients in their home. Their insight is hugely valuable because if they have any concerns, they report back the issues to the Toronto Grace call centre and clinical team. It’s an informed intervention that makes us better at catching client decline earlier.
——
Danielle, would you say you’re very passionate about this RCM program?
Danielle: Quite honestly, I’m very engaged and passionate about our RCM program. A lot of remote monitoring programs are medical heavy —focused on patients with chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). The RCM program does medical monitoring, but our specialty is the non-medical monitoring. Falls detection, patients wandering, food security — all of these other elements are unique. In my opinion, the non-medical issues are most likely to lead to more ALC rates than COPD or CHF. These issues, like falls, wandering, and food security, are a sobering reminder of our aging population. I can’t speak enough about the way the RCM program has taken off— where we were and where we are now. How much educational learning we have done making the program more efficient and building a solid RCM team.
Thank you, Danielle, for a great interview!