Primary care teams support frail seniors

Ridge Meadows Division of Family Practice, Fraser Health, and community agency partnerships

Nineteen family doctors in Pitt Meadows and Maple Ridge are referring homebound frail elderly patients with urgent health concerns to a rapid response team that includes a mobile nurse who is able to see patients in their homes, and in many cases prevent or delay hospital visits.

Family doctors can send a nurse into the homes of vulnerable patients who might have a health concern requiring immediate care, need medical attention for wounds or falls, or are at risk for hospitalization. In partnership with the physician, the nurse can assess and treat these patients.

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.

During the Pitt Meadows and Maple Ridge team-based care pilot project – which was named “Nurse Terry” and ran for 10 months from April 2017 to January 2018 – 92% of the home visits provided prevented a patient trip to the emergency room (ER).

“It is a very collaborative model,” says Treena Innes, Executive Director of the Ridge Meadows Division of Family Practice. “The division, our Fraser Health partners, family doctors, specialists, non-profits, seniors’ networks, and patients are together at the table to test the model, get feedback, and make improvements. This is a great example of a true partnership.”

To enable the shift, Fraser Health is redesigning some of its Home Health services, which includes shifting nurse roles to provide rapid patient care in the home when elderly patients are having health issues and unable to see their physician. The nurse acts as a liaison for the family doctor, provides care in the home, and connects patients to a broader team of home and community health supports, occupational therapy and physiotherapy, and a seniors’ navigator.

“I have been working with Terry and it’s been amazing. I just make one call and she can connect with the Home Health team as well,” says Dr Catherine Pattinson.

Partnership with a non-profit senior’s outreach organization (Maple Ridge Pitt Meadows Community Services) has also played an important role. The group has funded a seniors’ navigator position to support further coordination of supports. “Patient navigation is critical with these patients and their families; it connects seniors with the services they need,” explains Innes. The combination of services aims to help patients avoid hospital visits and stay in their homes.

Anna Loch, who works as the seniors’ navigator, helps patients find support in the community and get connected to a family doctor if they don’t have one. She arranges for companionship, transportation, and Meals on Wheels. She also helps seniors with tasks such as completing forms or finding housing. During the 2017 pilot, she received about five referrals a week and made 250 connections with elderly patients.

A Seniors Resource Guide published by the Maple Ridge, Pitt Meadows and Katzie Seniors Network has been distributed to clinics and community centres to further inform patients, families, and doctors about the variety of seniors supports available in the communities,

Patients and their families appreciate the all-around support and say they would welcome the nurse back to their home if a future medical problem occurred. “The very rapid response was appreciated. We are definitely grateful for this service,” notes a family member. “The nurse helped me to exercise and motivated me on being active in my daily routine,” says one patient.

There is still work to be done to improve electronic medical record communication between doctors and nurses, and to manage change for nurses who have shifted from working in offices to partnering with family doctors and going into patients’ homes.

Sandy Drieschner, Manager of Maple Ridge Home Health and Home Support says that expansion of the program will enable primary care nurses to respond to urgent care needs of patients throughout the area.

“It’s been a great success, and we’re excited to be gearing up to expand it more widely across the community,” says Treena Innes. “The biggest ‘aha’ is how now nicely this has morphed into our vision for primary care networks that we are planing with our partners. It aligns perfectly.”

Starting in spring/summer of 2018, additional nurses will join four primary care networks in Ridge Meadows that will each support the patients of 10 to 20 family doctors.


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