Ontario’s New Health Care Announcement: Is It Enough?

Earlier this week, Ontario’s health minister, Dr. Eric Hoskins, announced that the province is making 1,200 more hospital beds available across Ontario. Of course, news that hospitals can take on more patients is always greeted with enthusiasm. But Monday’s announcement was also aimed at another crucial part of many patients’ care journeys: transitioning back into the community.

Specifically, the new funding will lead to 207 affordable housing units for seniors discharged from hospital and 503 transitional care spaces. It will also enable the reopening of 150 beds at Humber River Hospital’s Finch site and 75 beds at University Health Network’s former Hillcrest site to provide care for patients transitioning out of the hospital.

What does this focus on post-discharge care signify? And will these new beds and spaces make a real impact for patients in transition?

Another major step forward

As rates of chronic disease continue to rise, governments are recognizing the need for major changes to the way care is delivered. Our health care systems were designed for acute conditions. But sometimes hospitals are just one part of the solution.

Unfortunately, the transition back home isn’t always an easy one. From poor coordination to limited human resources, there’s no shortage of obstacles that can seriously compromise the quality of home and community care.

It’s a lesson the province has taken to heart. Since 2003, Ontario has doubled its investment in home care. A good chunk of recent funding has gone toward respite care for family caregivers. Family members provide so much of the support that many at-home patients receive. The formal recognition of their contributions is significant in part because it shows that the Ministry of Health and Long-Term Care is ready to examine the unique challenges associated with delivering care at home.

Of course, there are obstacles to improving care in any environment. But one of the surest ways to maintain continuity is to ensure that transitions between care environments are strong. For this reason, this province’s latest announcement represents a major step toward strengthening the system as a whole.

That said, there’s still a long way to go. Additional beds can improve care for those who use them. But what about the day-to-day challenges of the many patients who have recently been discharged from the hospital? Is there a cost-feasible way to offer personal support for all of them?

Further support for patients in transition

Recent funding aimed at health care transitions represents a major step in the right direction. There’s no doubt that the extra beds and spaces it provides will have an impact on the Ontarians who use them. Unfortunately, the problems associated with moving from hospital to home impact a much larger number of patients.

Take hospital readmissions, for example. A recent study from the Canadian Institute for Health Information (CIHI) reveals that 8.5% of discharged patients are readmitted to hospital within 30 days. Why is this number so high?

One of the reasons is insufficient support. When patients get home, they often feel anxious, confused, and (in some cases) alone. Who should they get in touch with about scheduling home care visits? How can they reach members of their care teams? And given that the details are hard to remember, how can they get their family members up to speed?

Low-cost health care apps can help at-home patients adhere to the lifestyle changes prescribed by their physicians. A videoconferencing app that connects entire circles of care can be especially useful. For a patient, there’s undeniable value in having her family doctor, specialists, nurses, personal support workers (PSWs), family caregivers, and other circle of care members all accessible in the same place.

And because these team members can check in any time, they’re more likely to catch potential issues that could create health complications for the patient—or even send her back to the hospital.

Studies also show that patients frequently don’t understand their post-discharge instructions. Transitioning to a new care environment can be a confusing time. Personalized educational content—such as videos that demonstrate at-home breathing exercises for patients with COPD—will be immensely helpful in the years to come.

In short, funding that makes more post-discharge beds and spaces available for patients transitioning out of hospitals is sure to make a difference. But technology can provide further support for more patients by ensuring they’re set up for success when they get home.

Feature image courtesy of Alex Guibord


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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

One 60-90 min session with the Educator

  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
COPD Education – Continuous Maintenance


To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Patient, Educator (Nurse, RT or Physician)

A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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