Better collaboration means better care for long-term care residents

The COVID-19 pandemic has highlighted the need for strong collaboration and clear communication among healthcare providers, particularly when it comes to vulnerable older adults. A unique partnership is creating a digital link between hospital and long-term care (LTC) homes to ensure clear, accurate information flows quickly and easily between the two healthcare providers when transferring patients, to reduce the potential for delays or errors in care. The intent is to improve health outcomes for older adults transferred between hospital and long-term care.

For hospital patients going to a LTC home, this means their hospital team will be able to send medical information to their LTC team – directly from the hospital system to the LTC home. The same will be true in reverse for residents of a LTC home going into hospital.

This fast, bi-directional exchange of medical information will bring many benefits, in terms of speed and accuracy of information, which is important now more than ever as we are faced with the challenges of a pandemic. COVID-19 has struck many residents of Ontario’s long-term care homes, prompting partnerships with hospitals to provide assistance and making the direct and rapid exchange of information between hospitals and LTC homes even more important to enable patient-centred care. While this initial project will focus on local Hamilton healthcare providers, the intent is to develop a successful digital tool to support hospital/LTC transitions across the province to improve the health outcomes of LTC residents. A large-scale improvement of this kind will be of interest to the recently announced independent commission into Ontario’s long-term care system.

St. Joseph’s Healthcare Hamilton (SJHH) and St. Joseph’s Villa in Dundas are the hospital/LTC partners involved in the project. Both partners already collaborate under St. Joseph’s Health System (SJHS), a leader in integrated care, creating this unique opportunity to test a cooperative pilot project.

The third partner is Canadian based PointClickCare, the leading cloud-based technology partner to North America’s LTC industry. PointClickCare is providing the solution, known as Harmony, to make this integration possible.

The project is funded in part by the CAN Health Network, as an innovative Canadian technology project developing solutions to address important challenges in our healthcare system. The CAN Health Network was created in July 2019, as a result of a Federal Government investment totaling $7 million, of which the Federal Economic Development Agency for Southern Ontario (FedDev Ontario) and Western Economic Diversification Canada (WD) each contributed $3.5 million. This investment established the Network in Ontario and the West, with expansion to the East, Quebec and the North to come.

Dr. Alistair Ingram, Chief of Medicine at St. Joseph’s Healthcare Hamilton, the hospital partner in the pilot project which aims to improve health outcomes for older adults transferred between hospital and long-term care.

Healthcare systems across Ontario often operate under different digital health record systems. For patients transferred between these healthcare institutions, the lack of standardization can result in paper-based transfer of information, written notes and potential delays in relaying and taking action on important medical information. Having an integrated care coordination platform can reduce the potential for medication errors, difficulties in obtaining an accurate diagnosis, delays in treatment and care, and readmissions to hospital.

The purpose of the pilot project is to connect various hospital health information systems with long-term care homes to support care coordination and delivery by enabling better information sharing. Following the pilot, the hope is to expand the solution to other healthcare providers across the province and Canada. Not only will the solution help with the transfer of COVID-19 patients from LTC to hospital, but it will also enable broader goals around integrated care and information sharing, which are fundamental to the success of the newly created Ontario Health Teams. Additionally, the solution could help reduce the number of unnecessary emergency transfers, as well as and the time that residents may be waiting for information and treatment.

Dr. Hugh Boyd, Medical Director at St. Joseph’s Villa, the LTC partner in the pilot project. Following the pilot, the hope is to expand the solution to other healthcare providers across the province and Canada.

A multi-disciplinary team from across SJHS will work with PointClickCare, which provides the cloud-based digital health information system used at St. Joseph’s Villa, to enable the secure two-way exchange of patient data with Dovetale (Epic), the hospital information system used at SJHH.

Once the benefits of the project are evaluated, the team hopes to expand the initiative to other LTC homes in Hamilton that use PointClickCare’s cloud-based platform, and then to many more long-term and acute care facilities across the country.

If the pilot is successful, additional hospitals and LTC homes in the CAN Health Network will be able to procure PointClickCare, strengthening healthcare and contributing to the growth of PointClickCare and additional job creation in Canada.


“The partnership created with the CAN Health Network, PointClickCare and St. Joseph’s Health System showcases Canadian talent in supporting our older adults in long-term care homes,” said Dr. Dante Morra, Chair of the CAN Health Network. “This initiative will help strengthen our healthcare system by addressing healthcare challenges like COVID-19 while helping Canadian innovators like PointClickCare scale faster across Canada.”

“This is one example of how we can improve communication between healthcare providers in our own community to make sure no one falls through the cracks,” says Dr. Alistair Ingram, Chief of Medicine at SJHH. “Having shared systems that talk to one another is a step towards the future of healthcare, where we see seamless connections between regional healthcare providers and easily accessible patient information wherever the patient is being cared for.”

“We know transitions between long-term care and hospitals can have the potential for medication errors and poor communication can hurt older adults,” says Dr. Hugh Boyd, Medical Director at St. Joseph’s Villa. “When transferring care many of us will try to send thorough information or call directly to receiving physicians, but this can sometimes result in over 100 pages being sent either electronically or via fax. This will eliminate clinicians wasting time sorting through fragmented data and allow more time to focus on caring for patients. This will save time and save lives.”

“St. Joseph’s Health System is pleased to partner with CAN Health Network and PointClickCare to enable ‘One Digital Health Record’ for our patient and residents,” says Fraser Edward, VP Partnerships at SJHS Centre for Integrated Care. “Clinicians need seamless and secure access to the right information, at the right time, within their Patient-centred Information Systems. Through this initiative we will be evaluating how PointClickCare Harmony solution can meet this important requirement and enable SJHS to better support older adults in long-term care and community settings.”

“To support person-centered care, blind handoffs of patient information are simply no longer viable,” says BJ Boyle, Vice-President and General Manager of Post-Acute Insights, PointClickCare. “Innovative providers like St. Joseph’s Health System understand that with the right technology, they can gather, interpret and act on timely insights to improve the patient journey across multiple care settings.”

“Thanks to the support of the CAN Health Network, this great example of homegrown innovation will be able to help even more Canadians,” says the Honourable Mélanie Joly, Minister of Economic Development and Official Languages and Minister responsible for the Federal Economic Development Agency for Southern Ontario.

“Canadians are innovative and entrepreneurial. Through the CAN Health Network, our government is helping entrepreneurs access networks of support and customers in Canada – turning more innovative ideas into Made-in-Canada success stories, like PointClickCare,” says the Honourable Mary Ng, Minister of Small Business, Export Promotion and International Trade.