GPs partner with nurses to support homebound frail elderly seniors

PSP Photo Dr Lawrence Yang.jpg

Surrey-North Delta division and Fraser Health partnership

When Adrianne Haynes became a caregiver for her husband Brian – a senior with multiple health challenges – she encountered ongoing challenges getting him the care and supports he needed. Brian’s mobility was limited and he couldn’t walk or leave his home to visit a family doctor or a specialist and had few options for home-based services. As a result, he experienced health problems, pain, and unnecessary emergency room (ER) visits.

Recognizing the need to improve care for patients like Brian, the Surrey-North Delta Division of Family Practice and Fraser Health collaborated to pilot a model of primary care in which family doctors partner with registered nurses to support homebound frail elderly patients.

In Surrey, Dr Lawrence Yang and his family practice partners at the Gateway Medical Clinic are working hand in hand with nurses, who make house calls to their patients’ homes. Adrianne – a former certified nursing assistant – is now providing input into that model as a patient advisor.

Adrianne says that Brian was not alone in his experience. “I’ve known of friends and loved ones who have gone to the ER a dozen times,” she says. She notes that when they get home, they don’t always know where to get support, or how to connect with recommended community services. Having limited mobility adds to the challenge.

“So often when these patients are stuck they go to the ER, which is not good for them or for the system,” says Dr Lawrence Yang. “So we know we have to redesign primary care for these patients.”

One way to address patients’ health issues before they become acute is to improve communication between family physicians and the community system, which has not always been in sync. Referrals to home-based health services may not include feedback to the doctor. Combined with that, family physicians may not be aware of the full range of community resources available to help their patients.

In the fall of 2017, the Division met with Fraser Health partners, who arranged to provide a primary care nurse trained in home health as a professional system navigator to work with family doctors and connect patients with community services. The approach of creating primary care teams in which family doctors, nurses and community providers work together to support frail elderly patients in their homes was inspired by the success of the “Nurse Debbie” model, started by the Fraser Northwest Division in 2016.

“My two practice partners and I started to refer our mild to very frail homebound patients to the nurse,” Dr Yang explains. “When the frail patient has a problem, the nurse can get to them quickly at home, get them activated, and reduce their use of the ER.”

“As an example, I had a patient with advanced lung disease who had developed severe leg swelling. I wasn't able to see him, and travelling was out of the question for the patient in his condition. The nurse went out to see him and learned that the swelling was related to something we could address. I was able to prescribe medication, and he didn't even have to leave his home or use the ER.”

In addition to assessing safety and assisting with acute medical needs, the nurse guides patients to self-manage their conditions and connects them to resources in the community. She also educates the GP team about the resources that are available for patients.

Dr Yang says the crux of the model – which is also one of the biggest hurdles to overcome going forward – is enabling nurses to access a physician’s electronic medical record (EMR) to share patient information in real time. Having a feedback loop is critical. “We can message her directly within our daily-use EMR,” he says. “She has all information about the patient. She books the appointment, and we can see notes she has left. I can see if my patient is safe at home.”

The team will measure impact; but, anecdotally, clear benefits are emerging. “We’re hearing from patients who say they are impressed with the care team collaboration and communication. There is no doubt they feel better cared for,” says Dr Yang. “As a doctor, I feel better, less likely to burnout, and energized by the partnership with the nurse, which is in full alignment with my desire to point patients to improved wellness.”

He notes that in addition to supporting the patients, the team-based approach to care is providing valuable learnings for family doctors, nurses and other providers; patients; data specialists; evaluators; and IT staff.

Margaret Meloche, Director of Operations, Fraser Health, Surrey Community is excited about the partnership and the model. “The successes and learnings are being applied to our redesign work in Primary Care and Home Health for Surrey. The physicians and planning team have been wonderful to work with,” she says.

“We know this is the right care for patients – treating them “just in time” and preventing ER visits, and connecting patients and families to community resources as needed.”


Read more about how primary care teams are keeping frail elderly patients out of the ER: