Purpose: Chronically ill older patients transitioning from hospital to home are at increased risk of readmission and complications. Numerous transitional care interventions have been proposed to improve communication and continuity of care throughout the transition. Evidence suggests that the risk of readmission and complications is reduced when interventions provide closer follow-up and multidisciplinary care. Informed by this evidence, the family medicine based virtual ward was developed by a Montreal family medicine group (FMG) to provide home-based care for patients with an elevated risk of emergency department (ED) visit or hospital readmission. The virtual ward team provides comprehensive, multidisciplinary post-discharge care at patients’ homes, combining the systems and staffing of the FMG’s home care program with a nurse case manager. Research was conducted to inform the implementation of similar transitional care programs in other Quebec health care settings. Methods: This research consists of a retrospective qualitative descriptive study of the implementation of the family medicine based virtual ward. Data was obtained from a semi-structured group interview with the team and informal interviews with individual members. Inductive thematic content analysis was used. Results: The following were identified as conditions for its successful implementation: 1) funding, 2) home care, 3) communication, 4) protocol standardization, and 5) continuous quality improvement. Conclusions: This intervention addresses the care of frequent health system users and compensates for gaps in communication and coordination. It was well-received by patients, healthcare providers and health system administrators and has the potential to reduce readmissions and reduce health system costs.
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