It is common for older people with different health problems to be admitted to the hospital. Upon discharge, they are left on their own and many return to the hospital or the ER. The goal of this participatory research project is to determine the effectiveness of a Family Medicine based Virtual Ward, offering a proactive follow-up program to older patients with complex needs. The intervention includes phone calls by a dedicated nurse, home visits by a family doctor, and multidisciplinary discussions about the patient (specialists, pharmacists). Ultimately, we expect to reduce the number of preventable readmissions based on research evidence.
Affiches présentées à NAPCRG en novembre 2016 :
- Insights Following the Implementation of a Family Medicine Based Virtual Ward
- Impact of a Family Medicine-based transitional care intervention on the use of hospital services in older patients (aussi présentée à la Journée scientifique annuelle du R1Q en juin 2016)
Nouvelles HGJ octobre 2016 :