Submitted by the North West Local Health Integration Network - February 13, 2019
Henry*, an 86 year old male, arrives at the Emergency Department accompanied by his two daughters. Henry’s wife was admitted to St. Joseph’s Care Group with a hip fracture three weeks prior. Before her hospitalization, Henry’s wife was independently caring for him. With his wife in hospital, Henry’s daughters report they have been overwhelmed and struggling to manage Henry’s health care needs. They also describe a recent rapid decline in his health over the last week. Henry’s health history includes Congestive Heart Failure and Chronic Obstructive Pulmonary Disease.
Henry is admitted to hospital with a diagnosis of dehydration and generalized weakness. He is treated with hydration through intravenous therapy, and begins a physiotherapy regimen with the aim to improve his overall strength and mobility.
Following the completion of treatment, a North West LHIN Community Care Coordinator visits Henry and his daughters in hospital to discuss discharge options. The daughters echo their previous concerns regarding their ability to manage Henry in his home while awaiting their mother’s rehabilitation at St. Joseph’s Care Group. The Coordinator works with the family to develop a comprehensive discharge plan that they can feel confident will meet Henry’s care needs.
For personal support, a Care Plan is developed to provide daily personal support services for assistance with bathing, personal care twice a day, and medication reminders. Recognizing Henry will require additional personal support for a period while awaiting his wife’s return home, the Coordinator also applies for funding through the Network of Individualized Community Enhancements (NICE) program. Designed to provide short-term service for individuals in extraordinary circumstances, this program can extend up to six weeks post-discharge.
A referral is also sent to the Rapid Response Nurse program. The aim of this program is to reduce re-hospitalization and avoid Emergency Department visits by improving the quality of transitions from acute care to home for frail adults and seniors with complex needs. Through this program, Henry will be seen within 24-48 hours post-discharge for a comprehensive physical assessment, medication reconciliation, health coaching and home safety check. Two to three additional visits can be provided as needed.
To address his mobility challenges, a physiotherapist will work with Henry to develop an exercise plan to continue the gains that were made while in hospital. Following six visits, Henry can continue to complete the exercises on his own or, if required, a personal support worker can be trained by the physiotherapist to assist.
Lastly, to address Henry’s risk of falls and promote regular primary care follow-up, the Coordinator arranges for him to be seen by a Nurse Practitioner. Visiting Henry in his home, the Nurse Practitioner will provide him with ongoing pain and symptom management moving forward.
The above basket of services provided by Home and Community Care enabled Henry to return home quickly while attending to all of his care needs met in his home. Rather than occupying a bed in hospital, Henry was able to have his health care needs met in a more appropriate care setting. Once his wife is discharged from the hospital, the Community Care Coordinator will visit the family in their home to reassess Henry’s needs and adjust his Care Plan accordingly.
* Names have been changed to protect patient privacy