Bridging Community and Acute Care
UPTAKE VC
Virtual Care for Safer Recovery After Acute Kidney Injury
Lead
Matthew James
Co-Lead
Neesh Pannu
Additional Contributors
Nusrat Shonmu, Tyrone Harrison, Moaliosa Donald
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Share this project
Bridging Community and Acute Care
UPTAKE VC
Virtual Care for Safer Recovery After Acute Kidney Injury
Lead
Matthew James
Co-Lead
Neesh Pannu
Additional Contributors
Nusrat Shonmu, Tyrone Harrison, Moaliosa Donald
Share this project
THE CHALLENGE
Acute Kidney Injury (AKI) is a serious condition that can cause long-term complications, including cardiovascular issues and recurrent hospitalizations. AKI often develops rapidly, and without proper management, it can lead to lasting health problems. A major gap exists in the continuity of care as patients transition from hospital to home. Without consistent follow-up monitoring or clinical oversight, patients with AKI face a heightened risk of severe and potentially irreversible health complications after discharge.
THE CHALLENGE
Acute Kidney Injury (AKI) is a serious condition that can cause long-term complications, including cardiovascular issues and recurrent hospitalizations. AKI often develops rapidly, and without proper management, it can lead to lasting health problems. A major gap exists in the continuity of care as patients transition from hospital to home. Without consistent follow-up monitoring or clinical oversight, patients with AKI face a heightened risk of severe and potentially irreversible health complications after discharge.
THE CHALLENGE
Acute Kidney Injury (AKI) is a serious condition that can cause long-term complications, including cardiovascular issues and recurrent hospitalizations. AKI often develops rapidly, and without proper management, it can lead to lasting health problems. A major gap exists in the continuity of care as patients transition from hospital to home. Without consistent follow-up monitoring or clinical oversight, patients with AKI face a heightened risk of severe and potentially irreversible health complications after discharge.
THE INNOVATION
The Virtual Home Hospital (VHH) program delivers hospital-level care at home through virtual technology and scheduled in-person visits. Designed to strengthen continuity of care, the program supports patients, including those with AKI, by offering tailored follow-up and monitoring services after discharge. VHH enables a safer, more supported transition from hospital to home and keeps patients connected to their care team during a period of heightened health risk.
THE INNOVATION
The Virtual Home Hospital (VHH) program delivers hospital-level care at home through virtual technology and scheduled in-person visits. Designed to strengthen continuity of care, the program supports patients, including those with AKI, by offering tailored follow-up and monitoring services after discharge. VHH enables a safer, more supported transition from hospital to home and keeps patients connected to their care team during a period of heightened health risk.
HOW IT WORKS
Patients enrolled in the VHH program are discharged with home-monitoring devices that allow the healthcare team to track key health indicators in real time. Through virtual consultations and scheduled in-person visits, providers can closely monitor the patient’s AKI progression, respond promptly to any health changes, and adjust care plans as needed. This approach mirrors the care continuity of an AKI-specific after-visit summary through a technology-enabled home care model.
HOW IT WORKS
Patients enrolled in the VHH program are discharged with home-monitoring devices that allow the healthcare team to track key health indicators in real time. Through virtual consultations and scheduled in-person visits, providers can closely monitor the patient’s AKI progression, respond promptly to any health changes, and adjust care plans as needed. This approach mirrors the care continuity of an AKI-specific after-visit summary through a technology-enabled home care model.
THE BENEFITS
For Users
Hospital-Level Care at Home: Patients receive structured follow-up and oversight without remaining in hospital.
Timely Monitoring and Intervention: Regular monitoring and timely interventions reduce likelihood of long-term complications.
Personalized Support: Patients receive guidance on managing AKI and other health conditions through virtual and in-person support.
Improved Adherence: Ongoing engagement encourages completion of follow-up care and treatment plans.
Greater Confidence and Independence: Support at home strengthens recovery while keeping patients connected to their care team.
For The System
Reduced Readmissions: Monitoring and timely support help lower AKI-related return visits and hospitalizations.
Efficient Resource Use: Delivering hospital-level care at home frees inpatient capacity and supports better use of care facilities.
Innovative, Patient-Centred Care: Demonstrates a commitment to decentralized care models that extend beyond the hospital.
Supports Virtual Care Adoption: Strengthens system readiness for virtual healthcare technologies and value-based care.
Scalable Home-Care Model: Structure can be adapted for other chronic conditions, contributing to long-term system evolution.
THE BENEFITS
For Users
Hospital-Level Care at Home: Patients receive structured follow-up and oversight without remaining in hospital.
Timely Monitoring and Intervention: Regular monitoring and timely interventions reduce likelihood of long-term complications.
Personalized Support: Patients receive guidance on managing AKI and other health conditions through virtual and in-person support.
Improved Adherence: Ongoing engagement encourages completion of follow-up care and treatment plans.
Greater Confidence and Independence: Support at home strengthens recovery while keeping patients connected to their care team.
For The System
Reduced Readmissions: Monitoring and timely support help lower AKI-related return visits and hospitalizations.
Efficient Resource Use: Delivering hospital-level care at home frees inpatient capacity and supports better use of care facilities.
Innovative, Patient-Centred Care: Demonstrates a commitment to decentralized care models that extend beyond the hospital.
Supports Virtual Care Adoption: Strengthens system readiness for virtual healthcare technologies and value-based care.
Scalable Home-Care Model: Structure can be adapted for other chronic conditions, contributing to long-term system evolution.
Get Involved
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