Since the late 1990s, the Ontario Telemedicine Network (OTN) has offered two-way videoconferencing to increase access to patient care and education for health care professionals and patients. However, until the implementation of the TC LHIN-funded urban telemedicine Withdrawal Management pilot project led by Toronto East General Hospital (TEGH) in partnership with UHN and St. Joseph’s Health Centre, this technology had not been used in Toronto’s withdrawal management sector.
This two year pilot project is “a completely new program and use of technology in a sector that crosses many hospitals,” says Pat Larson, the program’s Nurse Practitioner. The program provides access to primary care (provided by a nurse practitioner) for five non-medical withdrawal management sites associated with three Toronto hospitals – St. Joseph’s withdrawal management service; UHN’s Ossington and Women’s Own sites; and Toronto East General Hospital’s Aboriginal program and Withdrawal Management site.
After many years of experience and interest working with marginalized populations and tackling access issues, Pat knew immediately upon hearing about the TEGH-led project that she wanted to be involved in such an exciting opportunity with the potential to benefit clients and shift access at a sector level.
TEGH’s Withdrawal Management service, like the other TC LHIN sites involved, has traditionally been staffed by providers with expertise in addictions and social services but no medical training. The increasing medical, withdrawal-related and mental health complexity of clients being cared for in community settings, combined with growing Emergency Department (ED) usage for people with substance abuse issues, demonstrated that a new care model was needed. “Not only are the people we care for more medically complex now, but substance abuse is more complicated. There’s an explosion in substance options so more clients presenting in withdrawal management centres are in crisis,” explains Pat.
With little new money available but a clear need, the idea of telemedicine was put forward as an option with the TC LHIN funding the nursing resources and facilitating equipment through the OTN program. The goal was to improve access to primary care for both clients and staff.
Telemedicine has traditionally been funded to facilitate access within a specific specialty area, but in the case of withdrawal management, the funding is also being used to build capacity within the sector across the TC LHIN and to shift how the sector’s clients use ED services.
The pilot funds one nurse practitioner who provides primary care to patients and consults to staff at all five sites, both in-person and through OTN. About 73 per cent of the clients seen by Pat have a feature of complexity such as medical co-morbidities, a complex withdrawal, are unattached from primary care and/or are currently homeless.
Pat consults directly with patients to address medical issues, assist with system navigation and manage withdrawal. She also helps clients with mental health issues obtain support and does a lot of care coordination related to medication reconciliation.
Under the direction of the Withdrawal Management Services (WMS) Steering Committee, Pat was also tasked with program development. “This is a complex project to develop and coordinate as it involves five sites, required the development of agreements, operational systems and protocols, as well as setting up OTN equipment and training staff at each site,” Pat says.
An important component of the pilot has been capacity building to help non-medical staff understand and correctly manage risks which might result when individuals with complex medical, withdrawal and mental health issues are in WMS care. “There were no known detailed algorithms to help non-medical staff identify and manage complex risk issues, including polysubstance use and pre-existing medical problems,” says Pat. She is working with WMS supervisors and addictions experts to develop risk assessment and management practice guidelines for staff across all sites. It is expected that this will shift how withdrawal management clients use emergency services, both by decreasing non-emergency ED usage and ensuring that those who need urgent medical intervention will be sent promptly to the ED.
The technology has also facilitated other safety enhancements like weekly Virtual Rounds which are held with supervisors and staff at all sites, and OTN consults which are used to enhance access to addictions specialists and to obtain advice to help manage the care of complex clients.
The pilot’s success can be attributed to many factors including that the sector had been voluntarily planning together for nearly a decade with fully functioning steering and operations committees and that TEGH stepped forward to collaboratively lead the model development, work plan and evaluation strategy for the initiative.
Within this work, one of the challenges has been to design an electronic medical record (EMR) that is contiguous and accessible to the nurse practitioner from any site, as many clients use more than one program. The EMR has been implemented with TEGH as the health records custodian.
Additional safety enhancements have also been realized. For example, Pat identified that the transfer of information from the ED was a concern and that to improve care and safety, “staff needed good information from the ED in a way that would be easily understood by non-medical staff.” Using OTN technology she consulted with other hospitals to look at current best practice and developed a new ED transfer form that is now being piloted.
The WMS pilot will be externally evaluated to determine its success. Data is being collected to evaluate outcomes, e.g. numbers served, client complexity and types of referrals. Early client satisfaction scores are high with 98.5 per cent reporting good to excellent quality of care, 93 per cent reporting timely access to the nurse practitioner and 98.5 per cent reporting increased self-management.
Pat has no doubt of the program’s success. “I believe I diverted about nine per cent of the clients I saw in the first quarter of the year from the ED,” she says. She also notes the positive response of both staff and patients who appreciate the support and availability of medical expertise.
It is clear that the model can provide an opportunity to shift practice within the withdrawal management sector and has the potential to be an important component of a system that will ensure people receive the best possible treatment in the right location.