A report on a pilot innovative virtual method to deliver specialist medical care in Ontario suggests that “rapid-access virtual care clinics” can dramatically reduce wait times to see a specialist while winning accolades from patients. (JMCC Group is pleased to have supported this research.)
While the Covid-19 pandemic may have turbo-charged the change from in-office visits to virtual consultations with family doctors and other medical professionals, a new approach piloted by a Toronto-based neurology clinic may show the way to reducing stubbornly high wait times for patients to see medical specialists in various fields, thereby improving medical outcomes, quality of care and access for more patients overall.
According to a report on the pilot, recently published in The Canadian Journal of Neurological Sciences (CJNS), the median wait time to see a neurologist in Southwestern Ontario is 60 days while 32% of neurologists in Canada reported an average wait time of 24 weeks for non-urgent consultations. Increased morbidity, mortality, and costs to the healthcare system are some of the consequences of these delays. For example, for epilepsy patients, long delays in diagnosis and treatment result in greater risk of an increased number of seizures, seizure-related injuries and death.
The expansion of virtual medicine services has been one potential solution, the report points out. However, while virtual consultations have expanded access to specialists, especially for patients outside urban areas, wait times have remained unchanged as practitioners have merely shifted time spent in a clinic to the same time spent seeing patients virtually.
After studying these issues, the team at the Neurology Centre of Toronto (NCT) – a community-based, multidisciplinary neurology practice for adults and children led by Dr. Evan Cole Lewis (who is also JMCC’s Chief Medical Advisor) – concluded that the delivery of virtual medicine needed a rethink, especially from the perspective that the virtual visit should complement the traditional consultation, not replace it.
New Virtual Model Developed
The NCT team developed a new model, the Virtual Rapid Access Epilepsy Clinic (VEC) -- an online, “walk-in” style clinic, where appointments are conducted by video conference. The Virtual Care Team consists of an epilepsy specialist, a preliminary assessor (a physician assistant or “PA”, or a nurse with specialized training in epilepsy), and a social worker from Epilepsy Toronto – a patient advocacy organization with an extensive reach throughout Ontario. The pilot ran from April 4 to June 21, 2020, a period when Ontario’s medical system was under serious strain from the first phase of the pandemic.
The VEC model works like this:
After obtaining a referral, patients register online after which they receive an email with the time of their appointment, instructions, and a link to connect to their Virtual Care Room. (Appointments are booked every 20 minutes.)
At the start of each appointment, patient intake is conducted by a “Preliminary Assessor” (a PA or nurse) in a Virtual Care Room.
Then, a case review immediately follows in a separate Virtual Conference Room during which the Virtual Care Team discusses the patient’s situation and treatment plan.
The team returns to the Virtual Case Room to communicate with the patient, answer questions, connect the patient to community resources, and refine the treatment plan. Any further action taken is based on the individual needs of each patient.
After each visit, a treatment plan with follow-up instructions and an emergency contact protocol is sent to the patient via email, while a comprehensive report is sent to the referring physician.
In NCT’s model, a “triage” process eliminates cases that likely require a physical examination and confirms the appropriateness of patients to be assessed virtually.
Results Include Dramatic Wait Time Reductions
Preliminary results of post-visit surveys conducted with patients were highly positive about the VEC care model. Most patients (77% of survey respondents) were “very likely” or “likely” to use the virtual clinic over a traditional in-person appointment, even assuming that COVID-19 limitations are no longer a factor.
Wait time reductions were dramatic: while waits for NCT for standard appointments in April 2020 (prior to the VEC pilot launch) were four to six months, after launch, patients were consistently seen within two weeks of the original referral.
The NCT team’s descriptive report published in the CJNS supports “proof of concept”. Next steps include:
Detailed analysis that addresses safety and outcomes in comparison to traditional, in-person visits utilizing time-to-consultation as a quantitative metric,
Analysis of specific patient concerns to demonstrate and optimize care quality.
Given the high patient satisfaction with the VEC model, it continues to play an intricate role in the delivery of NCT’s services. NCT has now scaled the model to deliver virtual rapid access services for adults and children in headache and migraine, tics and Tourette’s Disorder, concussion and post-concussion syndrome; transfer of care between neurologists and medical cannabis for neurologic conditions.
Another big step has been a collaborative effort between the Hospital for Sick Children in Toronto and NCT, in which patients who present to the emergency department with new onset seizures are assessed within one week in the “New Onset Seizure Virtual Rapid Access Clinic”, which also uses this innovative care model.
Dr Lewis and his team were kind enough to answer a few additional questions for JMCC.
JMCC: It sounds like a big takeaway from your VEC pilot is that the Virtual Care Team model makes more efficient use of each team member’s skills and knowledge, particularly the medical specialist. And that this allows the specialist to see more patients per day, thereby decreasing wait times for all patients. Is that correct?
A: Yes, it’s important to remember that virtual care does not replace traditional care. Instead, it is just another tool that practitioners have in their toolkit. Many virtual care initiatives have taken a top-down approach while NCT’s bottom-up approach has allowed us to create a model that utilizes all of advantageous features of the virtual world rather than try to pack the traditional model of neurologic care into a virtual box.
We’ve created a new model of care that optimizes the independent skills of our team members and, thus, has allowed us to expedite care and see more patients while not sacrificing quality. It is a real patient-centred approach at heart. In fact, our aim in the coming months is to show that this model potentially delivers higher quality care than the traditional model when conducted appropriately and in the right circumstances.
JMCC: Is the addition of a social worker – in the case of your pilot, from Epilepsy Toronto – a novel aspect of your virtual care model? And what is that individual’s role?
A: Yes, the attendance of the social worker or child youth worker from Epilepsy Toronto is an invaluable addition. Normally, the practitioner refers the patient to community organizations like that after a traditional consult is completed. Often, the patient gets lost in the shuffle, does not follow through or might not understand the benefits of connecting with the community organization. With Epilepsy Toronto’s participation in the clinic, in the context of the consultation, their role and the help they can provide to the patient becomes abundantly clear. And I’m certain this leads to better outcomes for patients in multiple dimensions of their care.
JMCC: What was NCT’s biggest lesson from your pilot?
A: What a great question! It’s hard to pick just one thing we learned but I would have to say it confirmed for us that openness and a willingness to change are two key attributes of clinical practice. It’s easy for us to become rigid with methods learned through training and to become rather ossified in one’s way of practice. However, there’s always room for optimization and improvement and one has to be able to expose themselves to new ways of thinking and doing things, be vulnerable, take a chance … because you just may hit on something that can help a lot more people than you are already helping. Virtual care is exciting and stay tuned for what we have down the pipeline!
Readers can access the full report here (access fee applies): https://pubmed.ncbi.nlm.nih.gov/33988117/