New CLs link Acute to Community
Tatjana Orcic knows she is an important bridge between community and acute care in Richmond and she loves that role.
Tatjana and three other home care nurses are now employed as Community Liaisons (CLs) at Richmond Hospital. As part of the Care Transitions roll-out in January, the new CLs came on-board to work closely with medical, surgical, palliative and intensive care teams in Acute.
Their job? To pull patients from hospital beds and place them back into their own homes safely with appropriate levels of home care and support.
“We were introduced to strengthen interdisciplinary discharge planning by providing a home health lens,” Tatjana says. “The benefit of our community expertise is that if someone is admitted to hospital and is already known to home health, I can access patient information and care plans from community and share it with acute quickly. This means patients receive the care they need in a timely fashion. CLs also help identify appropriate community resources to enable timely discharge for patients. The longer a patient stays in hospital, the greater the risk for deconditioning and hospital acquired infections. We want to decrease unnecessary length of stays.”
“That’s exciting to me,” Tatjana adds.
Care Transitions, CLs & True North
Care Transitions — a partnership between Richmond Acute and Home Health — is the umbrella term for a series of initiatives that will ensure safe, quality care as patients seamlessly transition between home and community.
The introduction of CLs into Acute is but one of the initiatives that will ensure coordinated care is available to patients, clients and residents at the right time, in the right place, and with the necessary resources in place.
As such, Care Transitions — and all of its component parts — is inextricably linked to VCH’s True North goal of Providing the Best Care.
A made-in-Richmond approach
Community Liaisons are unique to Richmond. “They’re part of the home health community and they’re experienced home care nurses. That background is a big advantage,” says Jan Mathewson, coordinator of the Richmond Care Transitions team. “If the patient is known to community and we’re already providing services to that patient, we can bring information related to what their home situation is, what their family situation is, when they come into hospital. This way, we don’t have to recreate their story because our CLs know these people.”
Familiarity leads to improved care
Goals of the new CL team are three-pronged. CLs return patients to the comfort of their own homes quickly and safely. By doing so, length of stay is reduced. By supporting patients well in community, readmission rates can be reduced as well.
Tatjana says her familiarity with patients makes a big difference in not only the quality of care, but also to the patient’s comfort level.
“It’s great because I’m seeing patients in the hospital who I knew in community for so many years,” she says. “For them, we’re a familiar face, somebody they know and we’re a connecting link. I think it’s comforting for patients.”