Collaborations 2022

Scaling our products and services for greater impact.

The Medly and Bant programs are widely adopted by UHN patients as a result of their evidence-based effectiveness in improving patient quality of life, patient health outcomes, and in Medly’s case, reducing hospitalizations. Due to their nurse-led nature, which leads to finite resources, the program was only available for UHN patients.

The approach

In 2022, Medly began expanding outside of UHN to support excellence in heart failure care across Ontario. To date, Medly has expanded to 4 external sites with many more deployments in the works for this year. Patients and providers are now using the Medly platform at Couchiching Ontario Health Team (OHT), South Simcoe OHT, and Sunnybrook’s Transcatheter Aortic Valve Implantation (TAVI) and Heart Failure (HF) clinics.

In addition, there are currently 10 additional sites with pending agreements and/or strong interest in the Medly program, including a hospital in British Columbia (the first outside of Ontario).

UHN (including project team members from eHealth Innovation, Peter Munk Cardiac Centre, and Ted Rogers Centre for Heart Research), collaborated with BANAC stakeholders to implement and deliver diabetes and heart failure self-management through the bant and Medly programs, respectively.

Collaboration with BANAC and Ontario

In the summer of 2021, UHN began a collaboration with the Barrie Area Native Advisory Circle (BANAC) and Ontario Health to obtain funding for BANAC’s COVID-19 Remote Care Monitoring (RCM) proposal. Within the scope of that proposal, UHN (including project team members from eHealth Innovation, Peter Munk Cardiac Centre, and Ted Rogers Centre for Heart Research), collaborated with BANAC stakeholders (including Mamaway Wiidokdaadwin, Rama First Nation, and Beausoleil First Nation) to support with the implementation of a remote care monitoring service intended to support the self-management of diabetes and heart failure through the bant and Medly programs, respectively

The makwa (bear) represents healing. In the Anishinaabe Clans, Makwa is responsible for protection of the community and for healing. This bear is covered in the medicines that heal us and help us on the path to Mino Bimaadziwin (the Good Life). The bear image is property of the Barrie Area Native Advisory Circle and is used with permisson.

The impact

The Mamaway Wiidokdaadwin Primary Care Team has been able to deliver proactive care to their community members by facilitating faster access to urgent care in response to critical readings.
This RCM program has encouraged community members to engage in self-management health behaviors such as taking daily measures related to their chronic condition.
Program artifacts were co-designed with the Mamaway Wiidokdaadwin team to ensure a culturally safe and relevant approach to program socialization.

Through the implementation and delivery of the RCM program, UHN has supported and intends to continue supporting the achievement of the following project goals:

Product overview

Self-monitoring

Patient enters their diabetes-related readings into bant or heart failure-related readings into Medly.

Patient assessment

A Registered Nurse from Mamaway Wiidokdaadwin views this data on the clinical dashboard.

Timely support

If needed, a registered nurse follows up to ensure patients receive appropriate medical treatment.

Patient Stories

A patient who was enrolled in the bant program was trending with very high blood pressure over a few days. The Nurse Coordinator escalated the patient to the MRP, who advised the patient to go to the hospital. Upon admission, it was discovered that the patient
fit the criteria for the Medly program and was subse- quently enrolled into both programs.
Patient Stories

A patient enrolled in the bant program took an extremely high blood glucose reading and subsequently reached out to the Nurse Coordinator for support. After reviewing their data from the patient, the Nurse asked the patient to take a blood pressure reading, which also came back as extremely high.
After escalation to the Most Responsible Provider (MRP) and encouragement from both the Nurse Coordinator and MRP Physician, the patient went to the hospital where they were assessed and provided with the appropriate treatment.

Highlights

This Indigenous specific RCM program was co-developed with the following framework components:
1. Trauma-Informed
2. Sustainable
3. Patient Safety
4. Strengths-Based
During implementation, there was a strong focus on program socialization, community access, patients as owners of their health, and wholistic care.
The RCM program and nurse-led service delivery has ensured that patients remain connected to a clinical team trained in Indigenous cultural safety throughout their self-management journey.
With this program, patients are equipped with any necessary monitoring equipment and provided with direct access to a care team to support them in their diabetes and/or heart failure self management.