Innovation Spotlight: How Halton Healthcare Is Using SeamlessMD to Support Palliative Patients at Home

At the SeamlessMD 2026 Customer Conference, we had the pleasure of sitting down with Carlijn Kennedy, Manager of Community Integration and Halton@Home at Halton Healthcare, to discuss one of the most meaningful expansions of our platform to date: a digital care program built to support palliative patients - and their caregivers - in the comfort of their own homes.

The Challenge: Filling the Gaps Between Home Care Visits

Halton Healthcare serves the urban and rural communities of Halton Hills, Milton, and Oakville through three hospital sites and a robust network of community-based care. Their palliative care program has always been rooted in a clear mission: to relieve physical symptoms and emotional stress, and to preserve the quality of life and dignity of patients and their families - wherever they are in their journey.

But a persistent gap remained. Palliative patients living at home were high users of community services like paramedicine, often because there was no structured way to monitor their symptoms or respond to changes between visits. Community partners were seeing it firsthand: these patients wanted to stay home, but they needed more support than the existing tools could provide. The team saw an opportunity to do something better.

The Innovation: A Holistic Digital Program for Life at Home

Launched in May 2025, Halton's palliative care pathway on SeamlessMD was built from the ground up to support patients not just medically, but holistically - addressing symptom management, emotional wellbeing, advance care planning, and caregiver support all in one place. Critically, the program is open to all palliative patients, not only those with cancer, and patients can enter through multiple pathways: self-referral, community provider referral, or hospitalist referral.

1. Symptom Monitoring with ESAS Built In

Unlike surgical programs focused on short-term recovery, this program is designed for the long term - patients can be monitored for up to 12 months. Weekly symptom and health status questionnaires incorporate the Edmonton Symptom Assessment System (ESAS), a validated clinical tool that tracks pain, energy, nausea, anxiety, wellbeing, and more. Patients set their own reminder frequency - daily, every other day, or weekly - giving them a sense of control during a time when so much feels out of their hands. On the provider side, ESAS scores are automatically calculated and trended over time, giving the remote care management team a clear, longitudinal picture of each patient's condition without any manual scoring.

2. An Education Library Built for the Full Experience of Serious Illness

The program's education library goes well beyond clinical symptom management. Content spans advance care planning, mental health resources, grief support, complementary therapy, and - critically - dedicated resources for caregivers on how to support a loved one at end of life while also taking care of themselves. This last category reflects something the team felt strongly about: that supporting a palliative patient means supporting everyone around them. 

In early program data, 35 patients had already viewed over 800 education library pages - a signal of just how motivated this population is for trusted, accessible information.

3. A Higher-Touch Care Team Model

The workflows for this program look quite different from a surgical pathway. Rather than the intensive post-operative monitoring of the first few days followed by a gradual taper, palliative care requires consistent, long-term engagement with a different kind of clinical skill set - one focused on holistic wellbeing rather than recovery milestones. The remote care management team checks in regularly, responds to flagged symptoms, and brings both clinical expertise and genuine compassion to every interaction.

The Impact: Keeping Patients Home, and Feeling Supported

The outcomes from an initial cohort of 34 patients who were part of Halton’s remote care monitoring are striking. Comparing the six months before enrollment to the six months after completing the program:

• 93% reduction in ED visits
• 79% reduction in inpatient admissions
• 53% reduction in length of stay (1.6 days)

And across the broader palliative program:

• 71 patients enrolled
• 75% patient account engagement
• 83% of patients feel more confident managing their symptoms

But perhaps the most powerful measure of the program's value comes from the patients themselves. One shared: "I truly appreciate this program. It gives me comfort and peace of mind knowing that someone is monitoring my condition each day. Completing the daily health questions helps me stay aware of my symptoms and overall wellbeing." 

Another, after a check-in call from the care team, said simply: "I'm so glad you called me today. I feel so much better.”

A Look Ahead

What Halton Healthcare has built challenges a long-held assumption in digital health: that these tools are primarily for surgical or post-acute recovery populations. Palliative patients - people navigating some of the most difficult days of their lives - deserve the same quality of connected, proactive care. With plans to deepen community provider engagement and continue expanding the program's reach, Halton is proving that meeting patients where they are isn't just a philosophy. It's something you can build.

This work in palliative care builds on the success Halton has had using SeamlessMD to improve patient care with Digital Health for other areas as shown below.

We're proud to support Halton Healthcare in this work - and inspired by the care and intention they've brought to every aspect of this program.