Objectives: To determine the clinical and economic impact of a community-based, hybrid model of in-person and virtual care by comparing health-system performance of the rural jurisdiction where this model was implemented with neighbouring jurisdictions without such a model and the broader regional health system. Design: A cross-sectional comparative study. Setting: Ontario, Canada, with a focus on three largely rural public health units from April 1, 2018, until March 31, 2021. Participants: All residents of Ontario, Canada under the age of 105 eligible for the Ontario Health Insurance Plan (OHIP) during the study period. Interventions: An innovative, community-based, hybrid model of in-person and virtual care, the Virtual Triage and Assessment Centre (VTAC), was implemented in Renfrew County, Ontario on March 27, 2020. Main outcome measures: Primary outcome was change in emergency department (ED) visits anywhere in Ontario, secondary outcomes included changes in hospitalizations and health-system costs, using percent changes in mean monthly values of linked health-system administrative data for two years pre-implementation and one year post-implementation. Results: Renfrew County saw larger declines in ED visits (-34.4%, 95% confidence interval -41.9% to -26.0%) and hospitalizations (-11.1%, 95% confidence interval -19.7% to -1.5%), and slower growth in health-system costs than other rural regions studied. VTAC patients' low-acuity ED visits decreased by -32.9%, high-acuity visits increased by 8.2%, and hospitalizations increased by 30.0%. Conclusion: After implementing VTAC, Renfrew County saw reduced ED visits and hospitalizations and slower health-system cost growth compared to neighbouring rural jurisdictions. VTAC patients experienced reduced unnecessary ED visits and increased appropriate care. Community-based, hybrid models of in-person and virtual care may reduce the burden on emergency and hospital services in rural, remote and underserved regions. Further study is required to evaluate potential for scale and spread. Trial registration: Not applicable.

Jonathan Fitzsimon is the Medical Lead for the Renfrew County Virtual Triage and Assessment Centre (VTAC).

This work was supported by INSPIRE-PHC and by ICES, both of which are funded by grants from the Ontario Ministry of Health (award/grant number N/A). Christopher Belanger is supported by a postdoctoral fellowship with the University of Ottawa and Institut du Savoir Montfort (award/grant number N/A). Jonathan Fitzsimon is supported as the Medical Lead of the Renfrew County Virtual Triage and Assessment Centre (award/grant number N/A). Richard Glazier is supported as a Clinician Scientist by the Department of Family and Community Medicine at the University of Toronto and at St. Michael's Hospital (award/grant number N/A). Cayden Peixoto is supported as a Research Coordinator with the Institut du Savoir Montfort. Roshanak Mahdavi was supported as a Research Analyst at ICES uOttawa when the study was carried out (award/grant number N/A). Lesley Plumptre is supported as a staff scientist at ICES Central (award/grant number N/A). Michael Green is supported by the Brian Hennen Chair in Family Medicine at Queen's University (award/grant number N/A). Lise M. Bjerre is supported by the University of Ottawa and Institut du Savoir Montfort Chair in Family Medicine (award/grant number N/A).

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