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SE Health Develops Programs to Transition Patients from Hospital to Home
SE Health, a national, not-for-profit social enterprise, is a leader in the creation and development of Acute Care Transitions Programs. These programs are designed to deliver exceptional care and service to patients and families, ensuring a focus on continuity of care as they move from hospital to home.
SE Health has partnered with hospitals and community organizations on its Acute Care Transitions Programs since 2015. Today, with over 40 programs across Ontario, SE Health continues to build, scale and evolve, shaping the future of care at home.
“This innovative and integrated model is reinventing how we deliver authentic patient and family-centered care and inspiring our commitment to home care modernization,” said Nancy Lefebre, chief operating officer and senior vice-president at SE Health.
“Through strong partnerships and an interdisciplinary, flexible care model, we facilitate a safe and seamless transition from hospital to home for our patients and their families. We continue to enhance and expand this approach every day.”
Acute Care Transitions is an up to 16-week, integrated bundled care model that provides a direct path home for patients who have completed acute care treatment but require a complex post-acute care plan.
The program connects patients with community-based staff, social support services, primary care, and acute care teams to create personalized care plans that support their transition from hospital to home.
The program offers continuous support, a 24/7 helpline for additional patient and family support, a shared care plan, and the integration of cutting-edge technology that enhances care coordination and promotes self-management.
As part of its commitment to modernizing home care, SE Health has evolved many of its Transitions programs to include Remote Patient Monitoring for eligible patients.
“By integrating RPM into our programs, we are improving patient outcomes, enhancing quality of care, and making it easier for patients to manage their health at home,” said Shelby Fisch, vice president, Telehealth, Acute Care Partnerships and Rehabilitation Strategy at SE Health.
“For example, patients can monitor their blood pressure and respond to health assessments from the comfort of their home, while our teams provide timely support based on real-time data and escalate to the appropriate level of care as necessary.”
To ensure accessibility, SE Health provides data-enabled tablets to patients who may not have access to technology or the internet. RPM captures patient biometrics, personalized assessments, and standardized data triggers, allowing secure, real-time communication between care teams. This is particularly valuable in community settings, where healthcare providers often work independently but need a connected and collaborative care approach.
“SE Health is truly at the forefront as they continue to evolve this model of care,” said Joshua Liu, CEO and co-founder at SeamlessMD. “We partnered with them to co-design patient pathways tailored to their care model, ensuring patient and family needs come first. This is leading-edge innovation in action, and we are proud to collaborate with SE health as they bring these advancements to life.”
Over 80 percent of patients were able to remain at home once discharged from the program. Moreover, over 22,000 hospital/alternate level of care days were saved, and 94 percent of patients were able to work with their care team to adjust their care as needed.
“At SE Health, we go beyond delivering care – we create value-based care solutions that benefit hospitals, patients and communities,” said Kim Utley, SE Health’s clinical director, Health Care Solutions. “Our approach evolves with the healthcare system, continuously pivoting to meet new challenges and opportunities.
“We leverage technology, foster strong hospital relationships, and remain deeply committed to community impact and giving back.”
Originally published in Canadian Healthcare Technology Magazine