Comprehensive Program in Heart Function

Inside our RAPID clinic, nurse practitioners assess and adjust each patient’s care plan as needed. It is set up to manage high-risk patients with heart failure after a ER visit or hospital discharge, and helps transition patients to care with family doctors and cardiologists. Through the RAPID clinic, we are able to identify deteriorating symptoms earlier, and we have reduced one-week readmissions for worsening HF.

Our team in the Richard A.G. Robinson Heart Function Day Unit provides specialized therapy and interventions in an outpatient setting. This agile unit, in which critical IV therapies can be delivered quickly, has dropped ER visits and admissions as well.

Both units are part of an integrated care pathway so that people with heart failure have seamless follow-up care tied to their needs.

We have refined virtual visit platforms with secure messaging designed to be fully accessible to patients who can’t attend an in-clinic assessment, education session, or medication titration – thus extending the reach and scale of our digital health efforts.

We are working to expand Medly’s reach by helping hospitals, community clinics and primary care teams deploy this model of care to reach more vulnerable populations. We also strive to ensure care is delivered in a culturally relevant way – adapting language to align with unique cultural contexts for a respectful, seamless user experience.

Meanwhile, our AI and statistical learning efforts study physiologic data, medication, lab results and real-time patient-reported quality of life data to transform care regardless of ethnicity, accessibility, distance or income disparity. One example is the TRANSFORM HF program’s unique, evolving partnership with Weeneebayko Area Health Authority in Northern Ontario.