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Resources for eConsult Senders
Primary Care Providers (PCPs), delegates
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Resources for Ontario Health Teams (OHTs)
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Long-Term Care Resources
How can eConsult help in long-term care?
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Provide timely access to non-urgent questions (average response time 2 days)
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Improve care coordination and collaboration between clinicians
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Provide opportunities to enhance learning and manage resident cases within the home
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Avoid unnecessary resident transfers to acute care settings
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Offer an innovative approach to the referral/consultation process
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Address gaps in care for residents unable to travel for specialist visits
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Lower costs and burdens on the home, residents and caregivers
742 residents living in LTC in Ontario had an eConsult sent on their behalf between January 1, 2017 and December 31, 2019. eConsult has shown positive impacts in LTC, with providers and caregivers rating it highly and encouraging wide-spread adoption. Of the 407 cases submitted by providers in LTC on the Ontario eConsult Service, 80% were resolved without the need for the resident to attend a face-to-face visit with a specialist. Further, in 56% of cases, providers received advice for a new or additional course of action.
eConsult LTC Utilization and Savings Estimator
Guide: eConsult LTC Utilization and Savings Estimator
User Guides
Sample Cases from LTC
Provider Question
[Elderly Patient] now residing in long term care due to progressive dementia. Hx of vertebral fracture and hip fracture while taking [medication 1]. Continue to ambulate independently with a 4ww and likely at high risk for future fall and potential fracture. [PCP gives CrCl reading]. [Patient] is unable to tolerate swallowing pills whole. LTC guidelines from 2015 suggest [medication 2] may be beneficial for fracture prevention. Transfers for outpatient appointments have become increasingly challenging due to frailty. Could you recommend which treatment might be best in this frail ambulating [patient]?
Specialist Response
Thanks for the eConsult. The history of fragility fractures puts this patient in the severe osteoporosis category. If [patient] has no history of radiation, malignancy in the bone, hyperparathyroidism or hypercalcemia, then [medication 3] could be a treatment option. This is the only medication we have approved for osteoporosis therapy that targets osteoblastic activity to build new bone. It is expensive though (about $1000/month for up to 2 years) and it is not covered by Ontario Drug Benefit. It is administered SC on a daily basis. A simpler and cheaper treatment option would be [medication 2], and it should still offer significant benefit in terms of fracture protection. [Specialist gives suggested dose.] In this patient's case, the cost of [medication 2] should be covered [by ODB].
Provider Question
[Elderly patient] w/ hx of dementia and [PCP lists other chronic conditions], wheelchair bound requiring lift transfer residing in LTC w/ hx of [skin conditions]. Patient and family describe history of the attached image skin lesion noted centrally on low-back progressively accumulating scaly-type keratotic material over last 4 months. [PCP provides picture and detailed description of lesion, suggests Bowen’s as possibility]. This patient is very frail and arranging transfer for further assessment or procedure would be quite challenging. If any in-home treatments could be considered as a first step, the patient and family would surely appreciate this option. Your assessment and recommendations are truly appreciated. Thank you!
Specialist Response
The raised portion of this lesion has a "cutaneous horn" appearance. I agree with you that Bowen's Disease (Squamous Cell Carcinoma in-situ) is a possibility. A skin biopsy would provide a histological Dx re. Bowen's or a Squamous Cell carcinoma no longer in-situ. However if a biopsy is problematic in this setting, I suggest the following: The lesion is too large and raised for cryotherapy; try [medication 1] for 3 weeks. This will cause a brisk inflammatory reaction if the lesion is Bowen's disease. This may be painful and the treatment may have to be stopped after 2 weeks. Then treat the area with [medication 2] to decrease the inflammation.
Provider Question
[Elderly patient] w/ moderate to severe dementia and [PCP lists other chronic conditions] now residing in long term care. Family report pt was dx w/ PMR approx 4-5 years ago when unable to climb stairs. Pt was last seen in rheumatology f/u 3 years ago when [medication 1] had been tapered to [value] daily. Pt has remained on same dose since. Family report no recurrence of PMR since original diagnosis. Oral [medication 2] treatment has been limited by poor renal function [PCP gives CrCl reading]. Recent b/w showed ESR normal and CRP sl. elevated [PCP gives values]; however previous values are not available for comparison. Firstly, could a slow [medication 1] taper be initiated in this pt in an effort reduce overall # risk as pt remains ambulatory and high fall risk? Should b/w be monitored for signs of inflammation if this is pursued? How slowly should [patient] be tapered from [value]? Secondly, should we consider [medication 3] in this pt given high # risk and poor renal function? Your insights are greatly appreciated. Thank you.
Specialist Response
Good evening and thank you for your eConsult: If this patient has been stable with no symptoms suggestive of recurrent PMR then I would definitely be in favour of decreasing [medication 1] slowly. I would probably bring it down by 1 mg/day every couple of months as [patient] has been on it for so long. I would monitor it with ESR, CRP every couple of months and clinical status. [Medication 3] would be a very reasonable consideration, as [patient] is at very high risk for future fractures. Make sure [patient] is getting lots of calcium and vitamin D and that vitamin D level is in the normal range.
