Supporting seniors to stay healthy in their home is one of the health care system’s greatest challenges; accomplishing it is one of Fraser Health’s greatest achievements.

A key role in supporting Fraser Health’s ‘Home is Best’ philosophy is the Home Health Surveillance Nurse. Eleven Surveillance Nurses are part of the BC health authority’s comprehensive strategy to prevent admissions and readmissions to hospital and to help seniors avoid assisted living and residential care.

Surveillance Nurses make regular phone calls to the Home Health program’s senior clients.  They use a structured approach that covers the common concerns of seniors, help them set health goals and let them know what community resources are available to support them.

“It’s a partnership,” says Jan Jensen, Fraser Health’s first Surveillance Nurse who works in the Chilliwack area on the outskirts of Vancouver. “It’s about planning with the client versus telling them what to do. We all know that telling people what to do doesn’t work. We have to want to change in order for the change to happen.”

Community Care Professionals (CCP) from Home Health first conduct an in-person comprehensive assessment of clients and develop care plans in response to the assessment. Only clients who are stable on a care plan are transferred to the care of a Surveillance Nurse for follow-up sessions. This frees up the CCP to focus on more complex clients.

Part of the role of a Surveillance Nurse is to manage care transitions with their clients; they are committed to follow-up with their clients on the phone within 72 hours of the transition from hospital to home. Since the Surveillance Nurse program started in 2010, evidence shows people in the Home Health program are 3.4 times less likely to end up in an assisted living or residential care home, or deceased.

Jensen has 250 clients she keeps in touch with by phone on a regular basis. The commitment is to call every six months or more frequently, depending on need.

The spirit of the Surveillance Nurse embodies CARE management, the clinical approach to care for Home Health; it honors seniors as people who are capable and wanting to “do for” themselves.

Fraser Health developed the Surveillance Nurse role as part of the implementation of Integrated Health Networks. Other health authorities have expressed an interest in the role, and Home Health is working with them to help them adapt it to their needs. An article was published in the December 2014 issue of Geriatric Nursing about this work – “The effect of a ‘surveillance nurse’ telephone support intervention in a home care program” – written by Fraser Health’s Ron Kelly, interRAI Evaluation & Research Specialist and Lori Godin, Clinical Project Leader.