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A collaboration greater than the sum of its parts

Patients living with one or more chronic illnesses across the North East may soon be receiving a visit from Paramedics, but not for an emergency lift to their local hospital.  

The North East Community Care Access Centre (CCAC) and the Emergency Medical Services (EMS) of the Manitoulin-Sudbury District Services Board (DSB) recently teamed up to begin leveraging their individual strengths and working together to extend the resources of two important programs designed to support people in their homes.

Since 2012, the CCAC's Telehomecare program has been providing easy-to-use health monitoring equipment to patients dealing with heart failure, chronic obstructive pulmonary disorder, and/or diabetes. Thanks to this remote symptom and vital sign monitoring, and phone-based health coaching, patients have learned how to manage their disease and improve their overall health.  

Recently, when the DSB launched a pilot project that utilized their EMS staff to monitor vulnerable patients and conduct home visits, leads for both programs quickly identified an opportunity to create something greater than the sum of its parts. A plan was hatched between the CCAC and DSB to trial a model that would see the Telehomecare program continue to provide the monitoring and coaching, while EMS performed the equipment installations and retrievals during their home visits. 

"By coming together, we can provide an enhanced service for the patients of both organizations beyond the original vision for these programs," says Tammy Windsor, Manager, North East CCAC Telehomecare Program. "It is better for the patient and better for the system when we collaborate and communicate."  

Now, if a Telehomecare nurse becomes concerned with a patient's health status or the patient stops submitting data, they can notify both the patient's primary care physician and EMS, who will then visit the home to check up on the patient and administer assistance if required.   

According to Michael MacIsaac, Chief of Manitoulin-Sudbury DSB EMS, "Together, we believe we can provide early intervention for patients, avoid ambulance trips and Emergency Department visits, and reinvest resources into patient care."    

To date, a Memorandum of Understanding between the two organizations has been drafted, and CCAC Clinical Services Engagement Lead Melanie Tulini has held a "train the trainer" session with EMS Commander of Training David Wolff, who is now scheduling training with other DSB sites.  

If the trial is successful, the Telehomecare/EMS partnership could become a model for collaboration between CCACs and EMS in other areas in the North East.