COPD clients in Prince Albert Parkland receiving support at home, avoiding ED visits thanks to innovative new program

senior woman portrait before cloudy sky, theree is still some sunshine

Health regions are exploring new ways to deliver services that better meet the needs of patients and clients. Several of these innovative practices were highlighted at the April 21 meeting of the Provincial Stakeholder Advisory Group, which helps steer the ED Waits and Patient Flow Initiative. While three of the four new programs are community based, all hold significant potential for shortening ED waits and improving patient flow in acute care. Today, we profile Prince Albert Parkland Health Region’s innovative Home First program.

Seniors with chronic conditions often end up in EDs or getting admitted to hospital when their symptoms flare up. In many cases, these trips to hospital could be averted if patients were better able to self-manage their condition and had a care provider help them where they live.

Prince Albert Parkland Health Region is using this model to deliver the right care in the right place to people with COPD (chronic obstructive pulmonary disease). Tanya Miller is a home care nurse practitioner (RN/NP) who is focused on supporting COPD patients receiving home care or living in personal care homes. Her clients are referred from Emergency, or by home care or personal care home staff, physicians, and palliative care. Miller visits or talks by telephone with people within 24 hours after they’re discharged from hospital or leave Emergency.

Under the new program, which started June 1, 2015, Miller has worked with 46 patients with COPD.  Her visits – which involve assessment, education, developing care plan, referring to and coordinating care with other providers such as respirologists – have dramatically reduced ED visits. Before the change, clients with COPD visited the ED 130 times; since the start of the home visits by Miller, that number has fallen to just 31, a 74% reduction.

Miller says one of the biggest benefits is being able to serve our clients in their homes.

“Transportation and mobility are huge barriers. COPD clients become incapacitated very quickly with exertion and their oxygen tanks can be cumbersome.” (Tanya Miller, home care nurse practitioner RN/NP)

She keeps family physicians and specialists up-to-speed on clients’ conditions and care by letter or phone call, and helps patients without a family physician to find one.

Clients like that they are better able manage their symptoms, have more timely access to care, and that there’s someone to advocate for them. “They are happy and thankful for the service,” says Miller.

, , ,

No comments yet.

Leave a Reply

Share your opinions and questions about this post. We welcome different points of view; but ask that you be respectful and constructive.  Your comments will be moderated before they appear on the site. Your Email address will be kept private.