Rethinking Health Care: Remote Care Monitoring at the Toronto Grace Health Centre

The world of health care has been turned upside down by the COVID-19 pandemic. But for The Salvation Army’s Toronto Grace Health Centre, it has provided opportunities for innovation and creativity. Just as the pandemic was beginning, the centre launched a pilot project called the Remote Care Monitoring Program. Using a pendant and the power of technology, the program allows elderly and at-risk patients to receive the health care they need from the comfort of their own home.

In this episode of the podcast, Jake Tran, president and CEO of TGHC, explains the Remote Care Monitoring Program, and Donna White shares her own personal experience with it.

Transcript

 Kristin Ostensen 

This is the Salvationist podcast. I’m Kristin Ostensen.

It’s an understatement to say that the world of health care has been turned upside down by the COVID-19 pandemic. “Business as usual” is gone. And that’s not always a bad thing. For The Salvation Army’s Toronto Grace Health Centre, it has provided opportunities for innovation and creativity. To rethink how health care is done. Just as the pandemic was beginning, the centre launched a pilot project called the Remote Care Monitoring Program. Using a pendant and the power of technology, the program allows elderly and at-risk patients to receive the health care they need from the comfort of their own home.

In this episode of the podcast, we’ll visit with Donna White, who is part of the program. Living in an apartment on her own, this 77-year-old Toronto resident feels safer knowing help is only a button click away. But first up, we’ve got Jake Tran, president and CEO of the health centre, who will take us through how the program works and why it’s so necessary.

So, I just want to start by asking you, when did this program begin, and where did the idea come from?

Jake Tran  

The program began approximately two years ago. And it was a pilot project. And the goal was to be able to bring at the time patients home so that they're not relying on hospital capacity. And the notion being—two years ago was the beginning of the pandemic. And so what we needed to reserve hospital beds for are those patients that are sick with COVID-19. And the ability to bring clients home and to be able to bring them home safely with remote care monitoring and using technology to have that in touch with the client or with the patient while they're at home allows for that extra security and extra safety for people.

Kristin Ostensen 

Yeah. So, can you tell me what's actually involved in remote care monitoring and explain the different components?

Jake Tran  

There's quite a bit of components. And I'll start off with the non-medical side. So, essentially, so if we have a client who wants to go home, and they tend to be very forgetful. So, the simplest way of monitoring them is, if they don't open their fridge during mealtimes, for example, we get an alert, because they did not open their fridge, we get an alert and what we do is we call them to remind them that it's time for your meals. And that then allows them to ensure that they are eating properly, they're getting the nutrition, that they don't become sick or to the point where they'll need to call 911. The other type of monitoring is with falls. So, they carry a pendant with them or a watch, and what tends to happen is that if they fall, and we automatically get a notification. And then we have direct communication with them in terms of helping them out, walking them through, we then make decisions with them in terms of who they need: a PSW to come in to help them, to assist them, or do they need 911. So, we're actually acting as the middle person having direct communication after a fall and to work with them in terms of getting them to safety, whether that means calling 911 or sending a personal support worker into their home to support them. Another piece of technology that we also have in place is if they wander. So, we have our older population, living with frailty in the community, where they tend to wander out of the house and not realizing that they're wandering out. So, we're able to geofence their house. So, if they set it up so that they're not supposed to leave their home at a set time, we can actually set that up. And if the door opens at 2 a.m. in the morning, then we get notification and so we then connect with them or with their loved ones so that we ensure that they come back home. Or if they are in the community somewhere and they're not supposed to, we are able to trace them. A good example is we have people who have gone missing from their home, we find out wandering on Queen Street in the middle of the night. So, we're able to track where they're at and bring them back home. So, these are some of the things that we do from a non-medical perspective.

Kristin Ostensen 

Wow, that's really incredible, to think that you could look after people and meet their needs so immediately, and yet not be there. How many patients are currently involved in the program?

Jake Tran  

Right now, as of today, we received over 1,500 referrals. We do discharge them if they get better and they don't need the system; we do take the technology away. Currently, in terms of actively being monitored, we're between 1,100 to 1,200 clients who are actively being monitored. A good example is, if they're being monitored and if something comes up, so there's frequent falls, what we also do is we have our wellness check. So, we automatically put the client into our wellness check team. And so, either a social worker or a PT or a physiotherapist, occupational therapist will then connect with them to make sure that they're OK, that they're doing fine over time. We will also connect with their primary care as well. So, their family doctors, if required, just so that they're being seen by the family physicians as well. So, creating a more of an integrated care.

Kristin Ostensen 

Wow, that is a huge number. What's the criteria for a patient to come on board with remote care?

Jake Tran  

So, we left that criteria very vague because, at the time, what we wanted to be able to do is, we wanted to be able to bring—they’re in the hospital so I’ll call them patients—but to bring them home. The criteria is that, one, we're looking at the older population living with frailty. They have risks of forgetfulness, of dementia, of falls, and that they have a health card. Having said that, we do have clients without health card, because we want to be able to serve the general population. So, the criteria is actually quite vague. And the key piece to the criteria is anyone living with frailty in the community, and anyone with risk in the community whereby we can actively prevent unnecessary use of the health system.

Kristin Ostensen 

Right. And you know, with an aging population in the country, I imagine that a program like this is only going to become more and more relevant and useful to the population. So, just thinking of that, what would you say are the key benefits of Remote Care Monitoring?

Jake Tran  

Our initial goal was to prevent unnecessary hospitalization. And so, the first goal was, why live in the hospital when we can find a way of bringing them home safely—safely being having the ability to monitor them. So that's number one. What we're also doing is making use of technology to monitor them in the home and proactively connect them to their primary care and to our wellness team, so proactively preventing them from calling 911, or from being hospitalized. So, those are two big benefits. And you know, the other piece is the ability to use technology, rather than health resources, given that in the past few years health and human resources is a valuable commodity, and we need to use the resources appropriately. And if we can introduce technology to do it, which then reduces the need for health resources.

Kristin Ostensen 

Absolutely. Yeah, as you say, we've seen incredible strain in the last couple of years, so anything that reduces that is such a huge benefit to society and health care system. Can you give me a couple of examples of sort of real life situations, how this kind of system plays out?

Jake Tran  

Yes. So, for example, we have an 85-year-old in an emergency department. This patient does not need to be admitted. However, she can't go home because no one's there to look after her. She lives alone. So, this is the ideal scenario where she goes home with our Remote care Monitoring and, immediately, once she turns it on, there is that second monitoring group, if you will, being able to oversee how she is doing at home. Then when she goes home, a lot of times what we find is the client then forgets to have their meals. What we do is we call them, and it tends to happen quite a bit where, you know, they wake up and they forget to have breakfast because they didn't open their fridge, or they forget their lunch, or they forget their dinner, and we then call them within the hour, and remind them that that's what they need to do. And we don't need their phone; their pendant acts as a two-way communication with us. They always will then have it, and then that will then allow us to monitor the client in the home. If they fall at home, we then directly talk to them using the pendant. And if they need to see their family doctor, we then connect them to their family doctors as well. So, it just allows us to then really have a close view, a close look of what they do at home. And we're at the point when this client is at home, we're also able to detect how often they spend in certain rooms. So, we now can map out their normal activities. And if there's something that's out of the ordinary—a good example is they, all of a sudden today, if on a normal occasion, in the morning, they spend half an hour in the bathroom because of morning care, and now all of a sudden she spends an hour, we get an alert. So, we do a call and say, Are you OK? Are you stuck? And our prime example is we have a client who is using a walker, and we noticed that she has not moved from her living room in one spot for a good hour. And then it increases to an hour and a half on the same day. And then when we saw that it was two hours, we called just to find out that she was not able to move because her walker was stuck in the carpet. And no one comes to see her until the next eight hours. So, we're able to then dispatch somebody to go help her so she's not stuck in one place for the next eight hours.

Kristin Ostensen 

Wow, that's incredible. And does that technology do it automatically—like it learns itself, and you don't have to program that in?

Jake Tran  

It does it itself because it learns your norm. So, it learns the person and becomes more individualized, and it knows over time, and we set limits so that it doesn't go off all the time. So, we set limits. So, we start off, and in the first week or so, as it's learning, we don't know what the norm is. And then over time, the longer they are on the system, we know and we can set limits. So, I know, you know, a client is in the bathroom in the morning, usually half an hour. So, we set a, you know, 15 minute minimum—in this case, the more important piece is a 60 minute max in the bathroom. So, if they spend more than 60 minutes in the bathroom, the question is, did they fall or are they stuck? And so we'll call as a safety measure. So, making use of artificial intelligence in this case has been quite helpful.

Kristin Ostensen 

Donna White has been a part of the Remote Care Monitoring program for about six months. Now 77 years old, she lives in a Christian retirement home on the west side of Toronto. That was how she found out about the program—from another resident in her building.

Donna White  

One of the girls in my building had one of these. And I look after the euchre group, and she was sitting there with hers and I said, Oh, can I feel that? How heavy is it? And I said, Oh, that's really light. I said I had tried one and it was much heavier, and I was always taking it off because I was so aware of it. This I don't even think of until I clunk it. So, we talked about it a bit and then she said it was free, and I said, "Come on.” And I mean, let's face it: most of us seniors are on fixed budgets, and some of us very minimal. If you don't have a pension plan or something, you're living on about $21,000, $22,000 a year. So, if somebody's going to give you something that you need for free, it's like, Are you kidding me?

Kristin Ostensen 

Donna was already interested in getting a medical alert device, after a close call at her sister's house last winter.

Donna White  

I had an incident in March. I was at her place. They were in Florida and I was filling the bird feeder, and I slipped on the ice and snow and went down and I couldn't get up because I have artificial knees. So, I had to crawl across the yard. And they have a railing that comes down their steps. So as soon as I touched the railing, I could get up—I just need something to hold on to. So, I got up and I was sopping wet because some of the snow and stuff was melting. And I remembered I had lost a friend last year who wore one of these—but not yours, another one. And she had made me promise when she was dying, that I would get one. And so, I said, Yes, yes, I will. So, when I fell that day, I thought, Oh, I did promise her. OK, I gotta look into it.

Kristin Ostensen 

Donna hasn't had to use the alert system yet. But she's glad to have it.

Donna White  

That's the big thing. It's like getting insurance—you hope you don't need it, but if you do, at least it's there. So I'm a happy camper. It does everything I want it to do. I just think it's terrific. The fellow who started this, he deserves a big pat on the back.

Kristin Ostensen 

Jake Tran is grateful for the feedback he gets from clients such as Donna, as it only helps make the program even better.

Jake Tran  

Every quarterly what we do is we request for feedback from patients, families, staff, as well as our referral sources. So, from a patient and family perspective, they really appreciate the fact that someone is assisting. And we're not intruding in their privacy either. So, the family members and caregivers truly appreciate the fact that someone's having oversight over a loved one at home. And especially in these days where a lot of the family members work, so they can't be home, looking after their loved one all the time, because they need to be at work. So, this is a second set of eyes, if you will, overseeing safety so that if something were to happen, that we would get an alert.

Kristin Ostensen 

Yeah, for sure. And I imagine this has been even more valued in the pandemic because there have been periods where all of us have had to be locked down or isolated, which means probably families were that much less able to go visit their loved ones.

Jake Tran  

Right. And then the beauty is, we're able to set it up so that if a family member or a caregiver would like to be the first to be in contact with their loved ones at home, that can be addressed as well. So, we don't necessarily have to be the first in contact—family can be that. And because we find that the majority of our population are the older population living with frailty in the community, they can simply tap their pendant or their watch and they can speak with their loved ones, right there and then, so we don't need the use of their Wi-Fi or their phone, to have direct connection with their loved ones or with us, depending on how it’s set up. So, it's certainly a good way to have communication, as required, giving them the privacy that they need, and then ensuring their safety while they are at home—you know, the idea of aging in place or successful aging in the community.

Kristin Ostensen 

Absolutely. I'm just thinking from sort of a higher level about the program, how would you say it aligns with the Army's mission overall?

Jake Tran  

It's interesting, the Army's mission in terms of serving the marginalized population and to be able to care for them in community, the majority of our population—I would say 70% of our population—are the marginalized. And those with medical needs, those with significant frailty, we're able to serve that population. To us here at the hospital, it's an important piece, because now we're able to take people home who are marginalized and may not be able to afford such technology. But we're able to then provide this technology so that they can be at home.

Kristin Ostensen 

Yeah, that's so key because many older folks are on fixed incomes, and I imagine that this kind of care could be extremely costly. Now that you're over two years into the program, what would you say you've learned since it began? How has it evolved? And, you know, has anything surprised you through the process that you didn't anticipate at the beginning?

Jake Tran  

In terms of what we've learned, we've learned how to run a program at this scale. I've never ever thought that we'll have 1,500 clients on the program. And as with any program, right before the pilot stage, you don't know if you have, for lack of a better word, all your ducks lined up. We don't know if we have all the risks, all of the safety in place. And what I've learned is, it's about taking calculated risks. And it's about having a big picture in terms of where you want the program to go, but start small. That's what I have learned the most. And to be very honest with you, in our first three months, we only had two patients on the program when we first started, and we started really small. And what I've learned from that is, start small so you can learn from every possible mistake you can make and the things that you don't think about. And you know, there's no playbook out there. There's no instructions—instructions don't exist so you learn as you go. So, by starting small, the mistakes are also smaller and allows you to learn. The other piece that's also important is, we did not push this program on to the clients. What we did was we asked if they're interested in the program, and those who agreed, what we did was—and what was really useful—was we brought them back as part of the advisory committee. So, the patient's family came in and worked with us and said, This is what we would prefer. This ABC works. This does not work. And because they are the user of this system, their feedback has played an integral success to the program. And because we took what they've experienced and made changes to the program in the past two years. 

Kristin Ostensen 

That's brilliant, and what an incredible way to involve people in their own care.

Jake Tran  

Right. And at the end of the day, they are using it, so why not make use of their experience? Which is much, much more valuable. And then traditionally, we think about expertise. And in this case, it's interesting, really, there is no significant expertise because it's a new concept, reasonably new concept. And so, why not use those with the experience to help you co-design the program? And so that's what we've done. It's been quite a successful journey from that perspective.

Kristin Ostensen 

Yeah, absolutely. Now, as you said, this is a relatively new concept. Is this the first program of its type in Ontario or in the country even?

Jake Tran  

We're not the only one. There are similar programs, but not to our extent, the way we’ve built it out. Our model, for our remote care—there are a few remote care monitoring systems in Ontario—but what we've done is we took both a medical and, in my opinion, the most crucial part, a non-medical monitoring approach. So, although we have the ability to monitor clients in the community in terms of their vital signs, which is an important piece, what we've also been able to do is more relevant, if you will, are the non-medical pieces, like the falls, the forgetfulness, the wandering. Those are the pieces that we've been able to put in place, and it's unique. And making use of technology and relying less on human resources and having a team to support them in the home when the need arises.

Kristin Ostensen 

Yeah, absolutely. Speaking of expanding, you mentioned that you're sort of looking to scale up as you said. Can you talk to me about that and what your sort of future plans are for the program?

Jake Tran  

My goal is to be able to, right now, the initial goal in the first year was Toronto Grace patients. Then, very quickly thereafter, we've expanded to the Mid-West Ontario Health Team. And then we've expanded to Toronto right now, and I'm going to fast forward it a little bit. So, as of today, we are, our geography, our referral from Burlington to Belleville, from Lake Ontario to Lake Simcoe. So, that's where we're at. The majority of the clients are in the core in Toronto and central, such as York Region. But our goal is to regionalize the program and work with other jurisdictions in Ontario so that we're able to then expand it and scale this to other regions as well.

Kristin Ostensen 

That's amazing. I hope to hear more stories going forward about how this program is positively impacting people's lives.

Jake Tran  

Yeah, we're actually doing research studies on it as well. So, that's the other angle that I was very interested in is, what types of clients are we able to care for in the home? So, we have that piece, from a research perspective. We're also looking at, are we able to avoid 911 calls? How many clients are we able to proactively prevent hospitalization for? So, we're working with a number of research teams, both quantitative, qualitative and mixed methods to look at the program and do actual evaluation, in terms of client evaluation, qualitatively. But we're also looking at a mixed method to look at the program in general, and then the impact of the program from a health system perspective. So, we’re working with the different universities like the University of Toronto, Queen's University and the University of Waterloo.

Kristin Ostensen 

That's great. Do you have any preliminary results thus far in terms of qualitative, quantitative impact?

Jake Tran  

Quantitative we do not as yet. But we do have people looking at data. Qualitative, I've put forward an experience-based co-design because we're using families and patients as part of the co-design. So, we actually put forward the co-design piece. And the goal is to be able to create different pathways. While folks are in the hospital, how can we then create different pathways to discharge patients into the community successfully? What are some of the barriers that we're looking at, what are some of the barriers, facilitators coming out of different experiences? Not only from the staff, from the caregivers, from the patient, and from administrators as well. And so, we're able to then, hopefully, to co-design, and with the result of creating different pathways into bringing people back home, into the community, living in their home. That's where we're at. And I'm hoping that in a year's time that we will be able to present both the qualitative, quantitative and the mixed method research.

Kristin Ostensen 

Yeah, that's great. I look forward to reading that. Well, that is it for me. I just want to thank you again so much for your time today.

Jake Tran  

That's great. Thank you, Kristin. Take care.

Kristin Ostensen 

Thanks for joining us for another episode of the Salvationist podcast. For more episodes, visit Salvationist.ca/Podcast.