Acute Care House Calls to Long Term Care Homes

Background

Objective

The goal of this program is to reduce unnecessary ED visits by long term care home residents, thereby reducing ED wait times and improving quality of life of LTCH residents. In addition, this program has created an innovative system of nursing peer to peer consultation between acute care and long term care nurses who have created opportunities for shared learning and knowledge transfer, ultimately building nursing capacity in the LTCHs.

Project Overview

Pilot funding of 250K was received in April 2009 with the program being fully operational by October 2009. The first 6 months of planning included identifying LTCH high referrers to the TWH ED, initiating an invitation to that group to participate, engaging in joint planning through a TWH / LTCH Partner Steering Committee and developing an implementation and communication plan. Highlights of the implementation plan include full orientation to Partner LTCHs, LTCH Family Council meetings, LTCH Director of Care and Physician consultation, development of Affiliation Agreements, union Memorandum of Understanding, and determination of equipment and supply needs. Great effort was made to build trust and respect partner expertise, unique processes and need for appropriate pace and boundaries. Other partners included representatives from Community Care Access Centres, Regional Geriatric Program, Psychiatric Outreach Program, Emergency Management Services (EMS) and other internal departments, like Human Resources, Legal Affairs, Infection Prevention and Control.

The program is based on a nurse consultation model and consists of a team of ED trained registered staff nurses who take their expertise in acute care nursing directly to the LTCH resident’s bedside.

When the LTCH nursing staffs are considering a resident transfer to the ED, the mobile nurses are contacted first, unless it is an urgent or emergent situation. This nurse-to-nurse consultation either occurs over the phone or in person. Together, with guidance from the LTCH physician, the nurse supervisor and the most responsible nurse for the resident, the mobile nurse will assess, suggest interventions and will initiate treatment either directly or in partnership with the LTCH nurse right in the resident’s home. However, if the resident or a family member of the resident prefers an ED transfer, their wishes have priority.

There are currently 12 LTCHs participating in the program: Belmont House, Castleview Wychwood Towers, Christie Gardens, Fairview Nursing Home, Fudger House, Hellenic Home, Kensington Gardens, Leisureworld St. George, Cedarvale Terrace, Maynard Nursing Home, O’Neill Centre and Vermont Square.

The Program is a Four Focus Model:

Prevention (Proactive Rounds)

Monday to Friday, 9am to 5pm
Mobile RNs will

• visit all partner LTCHs based on pre-defined schedule (when possible)
• proactively identify residents that may require emergency care
• establish relationships with LTCH staff
• work with LTCH liaison to ensure supplies are available and requirements are being met
• share knowledge with and provide coaching at the point of care with LTCH nursing staff
• facilitate necessary resident transfers to the ED as needed
• liaise with Psychiatry Outreach Program
  

Avoidance (Urgent Response)

Monday to Sunday, 9am to 7pm
Mobile RNs will

• answer phone calls from LTCHs in a timely manner
• review consultations from previous day and follow up with residents as necessary
• share knowledge with and provide coaching at the point of care with LTCH nursing staff
• facilitate necessary resident transfers to the ED as needed
• liaise with Psychiatry Outreach Program

Rapid ED Engagement

Mobile RNs will

• Link with Geriatric Emergency Management (GEM) Advanced Practice Nurse (APN) or other Geriatric APNs
• Establish and access quick specialty services including Interventional Radiology, Video Fluoroscopy and Blood Transfusion Services

Followup

Mobile RNs will

• Followup within 48hrs when resident from Partner LTCH has been discharged from TWH inpatient unit back to LTCH to ensure that discharge plans are sustainable.

Communication

It was crucial that the staff at the long term care homes knew that the Mobile RNs were available to provide consultation. Several materials were developed to help communicate the program to LTCH staff including, laminated badges, posters and brochures.

Figure 1: Decision Making and Communication Algorithm

Results

Nurse to nurse consultations

In the first seven months of the project, there were a total of 388 calls and visits made by the Mobile RNs. 265 of these interactions were nurse-to-nurse consultations. Of the consultations made by the Mobile RNs, 209 (79%) were for residents who without the program, would have been sent to the emergency department. The mobile nurse was able to provide care for 159 long term care home residents who would have otherwise been transferred to an emergency department for care, a 76% success rate.

Figure 2: Number of consultations and aversions (October 2008 to April 2009)

The majority (70%) of consultation requests in the first 7 months of operation were for hydration concerns, tube problems, pain, breathing concerns or infection issues.

Figure 3: Top five requests for consultation

The majority of calls were spread throughout the week confirming need for 7day week service but prompted a reduction of hours of urgent response service from 9am to 9pm to 9am to 7pm

Figure 4: Needs for Service

Ambulance transfers in the Toronto area

The number of transfers to the hospital made by Toronto Emergency Medical Services from original 7 of the LTCHs participating in the project decreased by 10% between the 4th quarter of 2007 and the 4th quarter of 2008. There were fewer transfers from 5 of the 7 LTCHs, indicating that there may be an opportunity to increase marketing at Fudger House and Belmont House in the future.

Figure 5: Toronto Emergency Medical Services (EMS) Transfers

One on one interviews with the Directors of Care

Interviews were conducted with the Director of Care (DOC) of seven of the twelve LTCHs: Belmont House, Castleview Wychwood, Christie Gardens, Fudger House, Kensington Gardens, Leisureworld – St. George and Vermont Square.

From the interview, the DOCs had strong opinions on what they thought were the strengths of the program. One strength identified was the program’s ability to safeguard the quality of life for LTC residents. Care in the home was deemed better than receiving care in the ED since the ED tends to focus more on acute issues and does not attend to other concerns. This improvement was seen especially in residents with dementia who tend not to do well in emergency settings. DOCs also noticed a reduction in emergency visits or waiting times. Other strengths include: promoting continuity of care, fostering collaborative relationships and enhanced communication between LTC and TWH especially providing a second opinion, encouraging problem solving and critical thinking among LTC staff.

• “It gives the nurses another professional to bounce an idea off or just to get a second opinion… there always was a tendency when anything happens to just phone the doctor and panic and send the person to hospital… now that the mobile ED nurses are coming in they are helping our staff to think more critically… maybe there are other things we can do rather than just sending somebody to hospital”

The DOCs also expressed their opinions on some improvements to the program. Some improvements include: augmenting mobile ED nurse skills, formalizing the teaching/mentoring role, assisting with direct admissions to ambulatory care units, having the program led by Nurse Practitioners, expanding the hours of operation and expanding the program to include retirement homes and/or assisted living facilities.

Furthermore, the DOCs have seen an interactive learning relationship among the mobile nurses and the LTC staff. They have seen that the mobile nurses have a wealth of knowledge and a passion for geriatric care.

Focus group with the Mobile RNs

Interviews were conducted with the four Mobile RNs from the Toronto Western Hospital (TWH).

The Mobile RNs believe that the strengths of the program include: reducing emergency visits or wait times, promoting continuity of care, fostering understanding and enhanced communication between LTC and TWH, bridging the knowledge gap between acute and long term care, providing support for residents and families and expanding nursing opportunities and scope of practice.

The Mobile RNs believe that there are some current challenges to the program that need to be addressed including: ambiguity about the role of the mobile ED nurse and the program and the need to augment skill sets.

Although there was some initial resistance from the staff RNs, the Mobile RNs have been recognized as a significant support because of the large LTC staff RN workload. The Mobile RNs understand the different skills and knowledge involved in this role including: communication skills, openness to sharing and learning, team work and commitment to each other as nurses and to the advancement of the nursing profession.

Interviews with physician stakeholders

Interviews were conducted with two physicians – one LTC physician and one hospital Interventional Radiologist.

The physicians see many strengths in this program including: reducing emergency visits or wait times, advancing quality of life for LTC residents, and bridging the knowledge gap between acute and long term care.

The physicians have seen an improvement in care. Issues that previously presented challenges are no longer present. They have seen a great collaborative relationship develop between the LTC staff and mobile nurses. Physicians are also impressed with the skills and knowledge that the Mobile RNs possess and would be pleased if this program were to continue.

Interviews with LTCH nursing staff

Interviews were conducted with nursing staff of seven of the twelve LTCHs: Belmont House, Castleview Wychwood, Christie Gardens, Fudger House, Kensington Gardens, Leisureworld – St. George and Vermont Square.

The LTCH nursing staff believe the strengths of the program include: reducing emergency visits or wait times, facilitation of the appointments and hospital transfers, timely response, fostering collaborative relationships and enhanced communication between LTC and TWH, providing support and follow-up for LTC staff, providing support for families, and saving resources. The staff members of LTC would like to see this program continue.

• “They do allot of teaching while they are here…. I believe we also appreciate that because it’s like we’re learning an added skill almost… we really benefit from them… actually enjoy finding out about the new things that are coming out, new techniques and so forth”

According to the staff members, some improvements that can be made include: augmenting mobile ED nurses skills, providing routine IV medication treatments and increasing hours of operation.

The staff members are pleased with the supportive and respectful relationships that have been formed with the Mobile RNs. LTCH staff RNs are pleased with the extra knowledge and skills they have been acquiring from the Mobile RNs, the excellent communication skills of the Mobile RNs and the preparedness of the Mobile RNs.

Cost effectiveness analysis

The cost of a visit with the Mobile Team is $126 (21%) less than a visit to the emergency department.

Assumptions

• Mobile consultation costs based on 1.6 aversions per day (results from January, first month with 12 homes).
• Mobile consultation clinical costs based on $34.26 per hour salary + 25% benefits (9 to 9 Mon to Sun and 9 to 5 Mon to Fri)
• Mobile consultation transportation costs based on 82 visits in January * $20 round trip / 31 days
• Emergency visit clinical costs based on Case Costing Data for 75+ yr old pt (direct and indirect) from Toronto Western Hospital, 2007-08
• Emergency visit transportation costs based on EMS and Ambutrans costs

Figure 6: Cost of a mobile consultation compared to an ED visit

Future Directions

Next steps will include negotiation of base funding through Toronto Central Local Health Integrated Network (TCLHIN) planning process. Once ongoing funding is secured an additional 5+ LTCHs will be added to the service roster with consideration of including more residential and assistive living facilities. Further work is required on establishing co created medical directives and expanding scope of nursing practice, building on point of care coaching and teaching, addressing shared electronic documentation as well as exploring easier, more environmentally and ergonomically safe bike transportation.

Conclusion

Focusing on key factors of Partnership and Innovative Service Delivery the Long-Term Care Emergency Mobile Program has been a success. The program is not only less costly than a traditional ED visit for a 75+yr old patient but has also significantly decreased ED transfers. In addition, anecdotal evidence supports improved quality of life for residents and enhanced nursing knowledge and expanded scope of practice. Stakeholders including Mobile RNs, LTCH Directors of Care, nursing staff and physicians all report positive results.

references

• Ackermann, R., Kemle, K., Vogel, R., & Griffin Jr, R. (1998). Emergency Department Use by Nursing Home Residents. Annals of Emergency Medicine, 31(6), 749-757.
• Drummond, A. (2002). No room at the inn: overcrowding in Ontario's Emergency Departments. Canadian Journal of Emergency Medicine, 4(2), 91-97.

Nursing has an opportunity to influence care delivery horizontally along the continuum of care. Where could you see this type of mobile nursing model facilitating the care experience within as well as outside of your health care organization? - Mary Jane McNally