Pivoting to virtual care during the pandemic: How our CQIs responded
When the COVID-19 lockdown hit, many of our faculty members who work predominantly in ambulatory specialties found themselves scrambling to adapt to virtual care. To help support this rapid change in care delivery, we convened a broad interest group of early adopters of virtual care. We met weekly at first, then biweekly for the last many months. The group identified cross-cutting issues, such as how to incorporate educational activities into, and replicate multidisciplinary models of care in, the virtual care setting. We also identified site-specific issues, e.g. the implications for scheduling and access to, and use of, medical records.
Some of the hospital sites developed their own committees. For example, Sara Mitchell, clinician in quality and innovation, neurology, and Phil Lam, clinician in quality and innovation, infectious diseases, at Sunnybrook — working with colleagues in the Department of Medicine, Department of Family and Community Medicine and hospital operations — created toolkits for physicians to deliver virtual care. They aided medical secretaries in familiarizing themselves with the new work-flows and identified efficiencies that needed to be addressed (e.g., related to transmitting electronic prescriptions). They also created an excellent checklist for patients on what to do to prepare for a virtual visit.
We continued to work on cross-cutting issues as a group, but the intersection of virtual care and medical education presented such a major challenge that we struck a specific working group, led by Brian Wong, director of continuing professional development and quality innovation for the Department of Medicine. This Virtual Care Education Working Group includes 23 clinicians in quality and innovation, clinician-teachers, and trainees. Phil Lam, McKyla McIntyre and Tara O’Brien identified various work-flow issues with common platforms such as Zoom and OTN that needed to be addressed to allow for trainees to conduct virtual visits — both from home and from clinical sites — and created the Virtual Care Handbook for Internal Medicine Residents; an initiative led by Leora Branfield-Day, Ahmed Omar, Rebecca Stovel and Eric Tseng. They’re now working on a faculty development workshop and are collaborating with the Department of Family and Community Medicine and the Wilson Centre to adapt modules on virtual care delivery for internal medicine and subspecialty training.
While many quality and innovation (QI) projects were halted as a result of the lockdown, many new projects were developed in relation to the pandemic, including LTC+. LTC+ is a hub and spoke model for providing virtual specialist care to residents of 52 long-term care centres (LTCs) in the Greater Toronto Area. Led by clinicians, researchers, and operational staff at Women’s College Hospital and WIHV, Sunnybrook, Unity Health, and Baycrest, this massive collaboration has integrated Toronto Paramedics services and community providers’ diagnostic imaging and laboratory tests into a care delivery model bar none.
Family physicians covering a given LTC home send a consult request and receive a call back within 30 minutes from a physician specialist or advanced practice nurse who can provide advice and organize services, including on-site diagnostic services and intravenous treatments, and arrange follow-up care — virtually or in person, as needed.
Analysis of the data in September, after being up and running since April, showed that several of the LTCs — the ones that were early adopters and used the service at least 10 times — sustained a 25% reduction in the frequency with which they sent frail, elderly patients to the emergency department.
A lot has happened in the QI portfolio over the past six months. But, as with other portfolios, it’s also been important to pay attention to wellness and make clear to the CQIs that their own well-being comes first. While virtual care and other changes brought about by COVID-19 created many opportunities for quality and innovation work, these opportunities have come at a time when many faculty members are least able to take advantage of them.
The majority of our CQIs are early career faculty members with young children; many are feeling overwhelmed by the changes to their work and home lives. The sense that academic opportunities may be passing them by adds to the stress. That so many busy CQIs consistently made time to participate in the virtual care interest group meetings, even when sandwiched between full slates of virtual visits of morning and afternoon clinics, really says something about the dedication of these folks. There was a palpable sense that these regular meetings contributed to their well-being. Yes, Zoom fatigue is real. But, a gathering of colleagues, especially when it includes unstructured time to just go around the group and check in with people so they can share challenges and tips, has intrinsic value. This message came through many times over the past eight months.