STRENGTHEN PARTNERSHIPS & COLLABORATIONS
Supported by The Salvation Army Health Network, working in conjunction with Ontario Health at Home, community caregivers, and GRIHealth (Global Research Institute in Health and Care Technologies), the Remote Care Monitoring (RCM) program aims to ensure that qualified clients — alternate level of care (ALC) patients (particularly older adults living with frailty) currently in hospital and those who have transitioned back to the community — can receive the assistance they need outside of a hospital setting. The Grace’s RCM program not only supports clients so that they are able to live in the community, it also helps to reduce hospital
overcrowding by ensuring speedier and easier transitions for patients moving from acute care settings to the community.
The “Time at Home” group exercises help prevent de-conditioning while also reducing social isolation and loneliness.
The program utilizes technological advancements to accelerate and expand these transitions. Electronic pendants allow for 24/7 virtual care, including the remote tracking of vital signs, medication compliance, and off-premises wandering.
As well, the pendants allow the program team to monitor a wide variety of in-home care issues, including slips and falls, and problems with basic daily activities such as turning off the stove.
Our chaplains call RCM clients to check in, offering social support to those without someone in their life to fulfill this role.
RCM clients benefit from the care offered by a social worker, an occupational therapist, a physiotherapist, a nurse, and a nurse practitioner. Additional clinical services have been added this year to support older adults living with frailty in the community. Together in Movement and Exercise at Home (TIME at Home), which is overseen by our team physiotherapist but is volunteer led, uses pre-recorded videos of physiotherapists leading participants in activation exercises. These exercises help prevent de-conditioning, which can ultimately lead to re-hospitalization. These group exercises also help to reduce social isolation and loneliness since eligible clients from different communities across Ontario are able to participate in groups together. The clients have a unique opportunity to interact with people from different locales and different walks of life.
RCM clients also have access to a number of outpatient clinics, including one that offers the services of a geriatrician. Through the RCM platform and the nurse practitioner, clients have access to the geriatrician for consultation and assessment. To provide more comprehensive community care, the Grace has extended the chaplaincy services. Chaplains can now call eligible RCM clients over the phone to check in and see how they are doing. They can provide social support, offering a listening ear to clients who are without someone in their life to fulfill this role.
The RCM program’s combination of data, clinicians, chaplains, and PSWs helps to inform clinical interventions and enables caregivers to be more proactive in helping to provide preventive care. A decline in a client’s health can now be detected earlier. The involvement of an allied health team member utilizing the client’s resources can provide the appropriate care at the right time, so they do not end-up in Emergency.