Rapid Response Nurses Provide Intensive Care to Keep Frail Elderly Safe

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Roy Brown is an active and independent 89-year-old who still drives, does his own shopping and cooking. Roy lives alone in his Oakville house, the same house that he has lived in for the past 65 years and shared with his wife who passed away two years ago.

Roy’s past reads like a Hollywood movie.

He joined the Royal Canadian Air Force in 1942 and served overseas where he was a gunner. He was shot down in Belgium, hidden by a local family and later was turned over to the Germans. He spent his 21st birthday in a German prison where he was repeatedly ‘questioned’ by the Gestapo.  Rescued by the Resistance, Roy returned to Canada where he served until 1946. In 1993, he went to Willems, France with his wife, where he was honoured by local dignitaries at a civic reception.

Fast forward 46 years. Today, Roy has multiple health conditions, including congestive heart failure, diabetes, COPD and hypertension. Studies have shown that there is a high probability that high-risk seniors, such as Roy, will be re-admitted to hospital within 30 days.

The Mississauga Halton Community Care Access Centre (CCAC) partnered with Halton Healthcare Services – Oakville Trafalgar Memorial Hospital and Trillium Health Partners – Mississauga Hospital to identify and provide intense care to vulnerable seniors with complex clinical needs.

The Mississauga Halton CCAC introduced Rapid Response nurses, part of an innovative new initiative, launched in January 2013. High-risk patients like Roy now receive an intensive level of care from highly-experienced registered nurses to remain safely at home.

Lynda Amodeo-Thomson, a Mississauga Halton CCAC Rapid Response nurse, met with Roy before his discharge from hospital and arranged to visit him at home the following day. During that first home visit, Lynda re-assessed Roy’s needs and ensured he was taking his medications as instructed. Lynda also helped Roy connect with his family doctor to arrange follow-up appointments.

Over the next 30 days, Lynda continually assessed Roy to make sure his care plan was meeting his needs and that he was taking his medication and visiting his doctor. She helped Roy identify his signs and symptoms to help him better anticipate when he might be in medical trouble.  Lynda also taught him ways to manage his health to prevent re-hospitalization.

This example illustrates the teach-back method that Lynda used with Roy to help him make the necessary changes to maintain his health.  She came up with an ingenious way of helping Roy with his fluid intake to prevent dehydration as he wasn’t drinking enough fluids.  She asked Roy for his favourite mug and explained that he needed to drink eight times a day from that cup.

As she explains, “My philosophy is to help patients self-manage their care, to teach them how and why they are doing particular tasks such as weighing themselves, watching sodium intake, etc. I want them to be able to recognize what’s normal versus what’s not, and to visit their doctor as soon as they recognize any warning signs.”

Since working with Lynda, Roy takes a much more proactive approach to his health and made the following changes:

He weighs himself every day. He needs to be extra careful of any rapid increase in body weight because he has congestive heart failure

He checks all the labels on the cans he buys in the supermarket to better monitor his sodium intake

He records his weight, his fluid intake, and what he eats daily on his computer and sends this information to his family doctor

Roy wants to stay out of hospital and avoid repeated visits to the emergency department. “It is great to work with Lynda. She is a good teacher. And, physically I am feeling better.”