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Using Telehealth for a New Model of Care Coordination

Posted by James Baker, Chief Medical Officer | April 27, 2019 |
James Baker, Chief Medical Officer


Case Study from Toronto Increases Collaboration Between Healthcare Stakeholders


Canadians have been using telehealth in many of the same ways as Americans, despite the fact that our northern colleagues have a Medicare-for-all system and the U.S. still has a for-profit model. Both countries currently use the technology for a variety of specialty scenarios for treatment. The positive outcomes are the same no matter what flag is flying over the healthcare facility.

However, while the U.S. has a patchwork of vendors and applications for telehealth, the Canadians have sought to systematize telemedicine for routine care delivery an coordination.

A recent study followed the effectiveness of the Ontario Telemedicine Network to determine its impact on care continuity and whether the system delivered high quality care and caring.

What it the impact of a telehealth model on care coordination between families, patients, primary, and specialty physicians? Can telehealth improve outcomes by increasing care continuity? What can Americans learn from the Canadian model?

Telemedicine for Chronic Conditions

Canadians, like residents in the United States, suffer from a host of chronic and debilitating diseases. Over one-third of Canadians struggle with at least one of 10 chronic disorders, including hypertension, osteoarthritis, diabetes, asthma, cancer, dementia, and more. These disorders cause 89% of all the deaths in their nation.

Like Americans, the residents of Canada struggle with obesity and heart disease. Smoking is a big problem, although the World Health Organization reports that the instances of obesity and smoking are dropping in the adult population. That’s good news, and WHO says the reduction has saved the Canadian system of healthcare more than one million cardiovascular deaths from 1070 to 2000. Further, the WHO estimates $1 billion could be saved if these numbers continue to drop for the next two years. Currently, 65% of the nation’s healthcare costs are attributable to people with these chronic conditions.

Using Telehealth for a New Model of Care Coordination


It’s obvious that the U.S. system of care struggles with these same health challenges in the population base. A big part of the issue is the complexity of coordinating care between interdisciplinary teams? How are Canadians coping with care coordination for residents who are struggling with at least one complicated chronic disease? The answer is that it is a national effort that leverages telehealth networks.

Toronto’s Health Links Telehealth Network

Toronto is the fifth largest city in North America with more than 2.6 million people. A recent study suggested some of the same issues that we face, including, “silos in patient records and care management are created, putting patient safety and outcomes at risk.”

Ontario’s Ministry of Health and Long-term Care initiative focuses the continuity of care and the elimination of silos in the sprawling nation’s delivery networks. To improve how care is delivered to these residents, nine Health Link telehealth hubs were created to host case conferences to coordinate care between “a group of interprofessional care providers and his/her solo family physician by video call.”

This virtual system of care continuity provides a more efficient use of resources by facilitating easy to use and free videoconferences to help meetings between patients and providers happen more quickly and for less cost. These meetings are help over a secure and private hub and spoke digital network that makes collaboration more efficient.

The communication system is called a TIP clinic, or a case conference conducted via a telehealth visit. These meetings are coordinated by a nurse, who schedules up to a one-hour care discussion between care providers and the patient who can be located across the province. These video visits, “target complex patients who may be referred by their primary care physician, from the emergency or the hospital, and could benefit from the support of an interdisciplinary care team including clinical specialists.”

Unlike the U.S., where the primary care physician is viewed as the clinical hub for treatment, it’s the job of the nursing teams to interact with patients and coordinate care. They also serve as a sort of nursing case manager, to keep members of the interdisciplinary care team up-to-date.

Telehealth Results

“Telemedicine is used to bring together a number of interprofessional providers and connect them, via videoconference, with these patients to discuss the best care plan for their unique needs. This saves the patient the time and stress associated with travel.
From the Canadian study

The average ages of these patients is just over 70 years old with three chronic conditions and two complicating factors. A review of the data from this new system of care showed:

  • 97% of patients and their caregivers felt that the system increased the chances that the patient’s chronic care conditions could be better managed.
  • 97% of the patients family care providers said they were hopeful that these tools would improve patient outcomes within the next six months.
  • 98% of clinical providers and patients say that they could use the telemedicine platform again.

The study also noted that the majority of these patients also experienced mental health issues in addition to their physical disorders, “but by delivering the patient care in a familiar setting – either their home or local physician’s office – patient anxiety was reduced.”

The report listed five primary outcomes from the application of telemedicine for patient care coordination in the region. Telemedicine allowed the healthcare community to:

  • Quickly schedule case conferences and improve care delivery and efficiency.
  • Increased access to programs and services through care coordination.
  • Primary care physicians stayed engaged with the patient throughout the care coordination process.
  • Collaboration between providers improved.
  • The ability to share data and best practices improved.

Implications for Care in the United States

“Telemedicine facilitates a comfortable environment for patients to discuss sensitive issues with a group of healthcare providers, without the intimidation of being physically situated in a room full of practitioners”
From the study

This particular application of telehealth could improve care continuity across an American system that is heavily siloed. The model seems incredibly effective for treating chronic and complex disease modalities while increasing patient engagement. The implications are that this hub and spoke model for care continuity is an effective way to provide more proactive care while potentially reducing hospital readmissions.

To find out more about this method of care coordination and delivery, visit


Topics: "telemedicine", Canada, telehealth cost, digital health, rural health, 2019 trends

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