Connected Care: A new program to improve transitions from hospital to home

SickKids provides paediatric home-care providers 24/7 access to SickKids nurses

The health-care system can be a complicated space for families to navigate. This becomes particularly difficult for families of children with medical complexities who depend on the use of medical technologies like ventilators and feeding pumps. When patients are discharged from hospital, families are often worried about finding consistent and reliable home care. Home-care nurses—who typically work independently—don’t usually have the same kind of immediate access to changing information and professional support as nurses working in hospital, especially during overnight shifts.

Sophia, whose 4-year-old daughter is a patient at SickKids, understands the challenges of transitioning from hospital to home and what it takes to feel confident that the care her child receives at home will meet her specific needs. Her daughter is dependent on a feeding tube and supplemental oxygen.

“I received a call from my daughter’s home-care nurse when I was out running errands,” says Sophia, a mom of three. “The nurse was in a panic due to a blocked feeding tube so I quickly returned home to help. I am often worried when I need to be away from my daughter.”

At the direction of the Ministry of Health and Long-Term Care, Toronto Central Local Health Integration Network (TC-LHIN) approached The Hospital for Sick Children (SickKids) to explore solutions to improve transitions from hospital to home and to support health-care providers who care for children with medical complexity in the home and the community. In 2018, in response, SickKids and the TC-LHIN partnered to launch a program called Connected Care, which aims to improve the experience for these children and families in the Greater Toronto Area (GTA) through virtual outreach and professional development initiatives for home-care providers, and educational opportunities for families. The Connected Care program is in line with the provincial government’s long-term plan to strengthen the public health-care system and supports the vision to provide more seamless, patient-centred care.

Connected Care recently launched an outreach platform that provides paediatric home-care nurses 24/7 access to SickKids nurses through chat, voice and video consultations. The goal is to support the care children are receiving and to further strengthen paediatric expertise among community and home-care providers outside of the hospital. Connected Care is currently training home-care nurses from home-care agencies within the TC-LHIN, including VHA Home HealthCare, SE Health and Safehaven, to pilot this service. The program will expand to include agencies from across the GTA in the coming weeks.

“Guidance from SickKids nurses will help home-care nurses feel more supported and give families greater peace of mind regarding the care their children are receiving. It’s a win-win scenario,” says Ethelyn Pilapil, Supervisor, Integrated Child and Family Nursing and Personal Support - Toronto Central, at VHA Home HealthCare.

Families receiving home care often lack confidence that their children’s complex needs can be met at home. “The launch of the Connected Care virtual outreach platform will expedite access to specialized paediatric nursing knowledge to support home-care clinicians and help to alleviate family concerns,” says Judy Van Clieaf, VP, Clinical Operations and Chief Nursing Officer at SickKids.

Connected Care partners with home-care providers and agencies to promote standardization of clinical practice through professional development sessions. The integration of simulation-based learning modules allows participants to apply their knowledge and skills into scenarios that may be encountered in the home, in a safe learning environment. In 2018, over 200 competency-based modules were completed by community and home-care providers who attended an in-person full-day training session at SickKids.

Education for families of children with medical complexity is another priority of Connected Care. A dedicated and centralized hospital-wide family education program focuses on providing timely, standardized yet individualized one-on-one education. SickKids staff provide in-person classes for family caregivers who are preparing to take their child home from hospital. In 2018, 250 families were supported during 550 one-on-one sessions. Families can also access additional learning resources on the Connected Care Learning Hub on the AboutKidsHealth website.

Visit the Connected Care website to learn more.