North Shore Quick Response Team (QRT) puts ‘Home is Best’ philosophy into action
A year ago, Mrs. Smith’s* prognosis may have looked quite different than it did this past February.
The 92-year-old arrived at LGH Emergency Department with a fracture of her lower leg from a fall. She was non-surgical but unable to weight bear. She also lived alone and was unknown to the community Home Health team. In the past, a similar accident might have resulted in Mrs. Smith’s being admitted to an acute care bed at LGH.
Thanks to the availability of the Quick Response Team (QRT), Mrs. Smith was discharged from the ED with the team’s support.
That decision was reached after Tammy Mulder, the QRT’s primary care nurse, and occupational therapist Jennifer Mathieson, were called to assess Mrs. Smith. The two did a joint visit at the client’s home after she was discharged.
Tammy then put in home support three times/day in the morning, noon and dinner so that the Community Health Workers could assist with dressing, toileting, sponge bathing and meal preparation.
Jennifer was able to assess Mrs. Smith’s home and how she would manage without being able to put any weight on her leg. Jennifer arranged for a commode, wheelchair, raised toilet seat and front door ramp.
The duo saw the client every other day to make sure she was managing with the supports. Home supports were adjusted several times to accommodate the client’s care needs.
“I also spoke with the family many times regarding senior resources in the community, supporting their mom in her wish to live independently and getting Lifeline into the home,” says Tammy, who is a firm believer in the “Home is Best” philosophy.
Birth of the QRT
Last summer, LGH established the Quick Response Team to work in tandem with the LGH ED iCare team. Since then, the QRT has expanded to include a third role – Rapid Response Nurse Practitioner Jennifer Honey. Together, Tammy, Jennifer Mathieson and Jennifer Honey help fill the gap between acute and community.
“Not every patient fits neatly into acute or community,” says Jennifer Honey. “The QRT is there to fill in the gap and catch those patients between acute and community.”
The two multidisciplinary teams work together in the emergency department to transition frail seniors safely and quickly back into their own homes and prevent readmissions. The teams work cooperatively to ease ED congestion and free-up beds for patients in need of admission to acute care.
“Mrs. Smith is a good example of a senior whose frailty is advancing but, with help, can continue to live safely at home with supports,” says Tammy.
Daily rounding and huddles
Tammy and Jennifer M. work as a team with one of them starting at 8am and the other at 10am.
At 11 a.m., the list of possible discharge patients is brought into a huddle for further discussion and consideration. Participation in the huddle includes, ED clinicians, Transition Nurse, and Clinical Coordinator, Social Worker, and physiotherapist and QRT.
Together, they address possible barriers to discharge and work together to finalize patient transition details.
Communication is key
With any complex and integrated health process, good communication across the entire care team, acute through community, is essential.
“As the team matures and as acute care gets more familiar and comfortable with engaging in their support to pull medically stable yet frail clients back to community we are finding that there is a real positive impact for clients who want to go home,” says Sujata Connors, Director, Community & Family Health.
“Communication between all teams in acute and QRT is essential for this success and I would say that the development of relationships between staff is crucial to this communication. They need to be able to see each other and know who each other are – not just be a voice at the end of a phone.”
Safely back at home
Mrs. Smith continues to live independently. The QRT stayed involved until she was weight bearing and the need for home support was no longer needed.
By working together, the ED iCare and QRT ensured that Mrs. Smith received the right care, at the right time but the right provider.
“It is an honour to work with these teams,” says Sujata. “They are so engaged and committed about the work they do and are successful every day in helping individuals realize their goals of going home and staying home.”
But there is one thing the QRT would like to change.
“Jennifer and I want to change Tammy’s name to Jennifer,” laughed NP Jennifer Honey. “Then we’d be the Jennifer trifecta.”
Need to reach the QRT?
- Tammy Mulder: 604-842-3839
- Jennifer Mathieson: 604-319-3297
- Jennifer Honey: 604-816-4205
*Not the patient’s real name.