Peer-to-Peer Clinical Team Benefitting Patients and Providing Greater Meaning for Virtual Care

Mary Curtis is delivering extraordinary, virtual, patient care.  At the same time, she’s also educating and supporting her peers on the frontline – empowering them with the knowledge and skills to be their best – every day.

For Curtis, a long time, Registered Nurse on the Clinical Practice Resource Team (CPRT) at SE Health – a national, not-for-profit, social enterprise – a care model like the one she’s enabling is bridging the gap from hospital to home, complementing the exceptional ‘home care’ SE Health is known for, and enhancing patient care at every turn.

“Our Clinical Practice Resource Team is a one-of-a-kind model that allows us to optimize the scope of practice and promote quality, personalized care,” said Kaiyan Fu, SE Health Vice President, Professional Practice and Quality.  “Since we started this Team several years ago, it’s become an increasingly useful resource for visiting nurses in the field and supports our already outstanding patient care at home,” added Fu. “It’s also a diverse team and includes nurses in a wide variety of specialties – from paediatric to palliative – and a Clinical Practice Coach.”
 
By telephone and using increasingly new, digital communications, the team of highly specialized Registered Nurses provides direct clinical support, 24/7, 365 days a year, to SE Health frontline staff in communities across Ontario.  Nurses call in or message the CPRT to inquire about a specific patient they are working with or a process for which they need more information.  Questions range from medication management, to sharing expertise on intravenous pain pumps, to applying specific policies and procedures.  The virtual team and the on-site care provider access the same digital platform to view a patient’s medical history and work together to find the best care solution. 

 “Frontline workers feel more confident when they have this kind of support and encouragement,” said Curtis. “I was a visiting nurse for 14 years and time management was a struggle for me.  Having the support of the CPRT is great, especially in difficult situations.”

The CPRT helps SE Health’s Service Delivery Centres by providing ‘just in time’ clinical education, critical problem solving, and consultation to front line staff. They also help to support the patient and their loved ones through the best possible end of life experiences and other difficult circumstances.

 “As part of referrals, we sometimes learn that a child is being discharged with a tracheal tube,” said Maria Teresa Salazar, SE Health Registered Nurse and Manager, CPRT.  “We need to move quickly and mobilize our team; making sure that a paediatric nurse is available and that the clinical practice coach and supervisor are ready to go.  Collaboration is key and within a short time we can personalize the care for the patient and ensure they have the best possible resources.  Having the support of a virtual team keeps everything moving and complements the ongoing excellence of our home care program.”
 
As a leader in best practices for living and aging well at home, SE Health takes pride in its use of digital technology that enables the CPRT to serve numerous community partners and programs by promoting collaboration that puts the patients at the forefront.

Some of these partners include prominent health care centres where SE Health collaborates with in-hospital teams that enable frontline workers to enhance patient care, ensuring a seamless transition for patients from hospital to home.

“When patients are discharged from the hospital, they are given a discharge kit that includes a tablet, armed with software that allows us to collect information about their health status when we aren’t there,” said Salazar.  “They fill out questionnaires about their symptoms and use a bluetooth-enabled blood pressure cuff to record their vitals.  When the visiting nurse arrives, they deliver the exceptional SE Health ‘home care’ experience but can also call in to the CPRT if they have questions or need additional support.”

SE Health is also practicing clinician-to-clinician support outside of the CPRT.  At a Hamilton-area health care centre, SE Health utilizes video conferencing between physiotherapists (in hospital) and physiotherapy assistants who are in a patient’s home.

“Virtual care is the cornerstone of our commitment to digital health; and looking for better ways to provide care is part of our DNA,” said Arslan Idrees, SE Health’s Digital Transformation Officer.  “The key question that we continue to ask ourselves daily:  how can we enhance people-centered care that we have been delivering for over 110 years?  By using digital as a foundation and focusing on state-of-the-art technology,” he added.  “Virtual care is about sharing the right information at the right time and enhancing the ability of all members in the circle of care (including patients and their caregivers) to make better decisions.”

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