SIIReN - System Integration & Innovation Research Network

Primary Health Care System

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"Virtual Ward: An Integrated Care Model for Hospital-to-Home Transitions for Adults with Complex Health Care Needs, A partnership between acute, community and primary care providers"
Presenter: Ifran Dhalla, St. Michael’s Hospital
June 11, 2010


The purpose of this project is to see whether a "Virtual Ward" reduces readmissions after hospital discharge. The Virtual Ward, which is based in Toronto, began operations in late March and approximately 40 patients have been admitted so far. A pragmatic, randomized controlled trial will commence shortly, in order to evaluate this new model of care.

The Virtual Ward is intended to support patients, their caregivers and their family doctors. To be eligible, patients must be admitted to a general internal medicine ward at one of the participating hospitals, be 18 or older, be discharged to the community or long-term care, live within the Toronto Central LHIN catchment area, and have a high risk of readmission, as determined using the LACE index.

Although patients being cared for in the Virtual Ward will reside at home, they will benefit from a hospital-like interdisciplinary team, a shared set of notes, a single point of contact, round-the-clock physician availability and increased co-ordination of specialist, primary and home-based community care for several weeks after hospital discharge.

This project is funded and supported by the Canadian Institutes of Health Research (CIHR), the Toronto Central Local Health Integration Network, the Ontario Ministry of Health and Long-Term Care, the Toronto Central Community Care Access Centre, St. Michael's Hospital, Women's College Hospital and University Health Network.

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