SIIReN - System Integration & Innovation Research Network

Primary Health Care System

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"Virtual Ward, South East Toronto Family Health Team
Vision: To provide for safe and seamless transition of patients between primary care and acute care.
Presenters: Kavita Mehta, Tia Pham
South East Toronto Family Health Team
December 16, 2010


Many older adults with complex health needs in the East York area of Toronto are re-admitted to the Toronto East General Hospital (TEGH) at a higher rate than average for Toronto. To better serve the needs of this complex patient population, a virtual ward (VW) was embedded in the South East Toronto Family Health Team (FHT), located across the road from TEGH.  The goal is to improve continuity of care and reduce rates of emergency department visits and hospital readmissions for patients over 65 who, at the time of discharge, are deemed high risk for readmission. The FHT includes physicians who can accept new patients so the VW service is available for unattached/orphan patients as well as for established FHT patients.


  • Partner with Toronto East General Hospital to provide this vulnerable high risk population with improved follow-up care after discharge.
  • Identify and assist a growing population of unattached patients who do not have access to primary care and thus, are at increased risk for hospital readmissions. 
  • Admit these patients to a Virtual Ward in order to assist with the transition back home from hospital (and hopefully reduce the risk of readmissions).

Implementation: A physician assistant (PA) in the FHT identifies older patients at high risk of readmission using the LACE (length of stay, acuity of admission, comorbidities and emergency room visits) score (both FHT patients and patients without a family doctor qualify). The goal for SETFHT is to enrol 100 unattached patients a year. The PA meets with the patient while still in hospital, follows up by telephone within 24 hours after discharge, and arranges a clinic visit within a few days after discharge. The VW team includes doctors, a pharmacist, a dietitian, and a nurse to help navigate the patient’s safe transition from hospital to home. The team offers individualized medical care, referrals to appropriate community support services such as Meals on Wheels, addictions counselling and patient education to improve self-management. Intensive VW follow up with daily telephone calls lasts about eight weeks. Previously unattached patients are rostered into the FHT.  The FHT is part of a telehomecare project and VW patients with chronic obstructive lung disease, diabetes and congestive heart failure receive telehomecare equipment for up to six months. Patients submit vital signs every morning, allowing staff to monitor chronic conditions virtually, home visits are arranged if necessary, and self-management is incorporated into daily care. 

Outcome measurements:

  • Health care utilization: 30day readmission; PA time spent monitoring; Drop outs, length of stay, # visits to FHT; CCAC services
  • Surveys: Health status – SF12; Use of health services; Patient experience/satisfaction
  • Clinical indicators as per QIIP measures r/t COPD, Hypertension, and Diabetes.
  • Also working on the IHI Coordinating Care for Patients with Complex Needs Collaborative

Also working with the Performance Improvement Planning and Evaluation, Health System Accountability and Performance Division for evaluation support for the program.

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