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Rapid response nurses to help patients at home

Some patients moving from hospital to home will receive transitional care through a new Rapid Response Nurse Program.

The South East CCAC has hired five nurses in a bid to reduce hospitalization and avoidable emergency department visits by improving the quality of transition from hospital care to home care for medically vulnerable seniors and children. Two of the nurses are assigned to cover Hastings and Prince Edward. Care co-ordinators who work at the CCAC office located in the Picton hospital will work with members of the health team to make referrals to the program. Most referrals are for medication reconciliation and to help ensure follow-ups with the patient’s primary care physician take place.

Rapid Response Nurses are to care for patients with complicated health needs in consultation with CCAC care coordinators, community nurses and other community health providers by making a home visit within the first 24 hours after the patient is discharged home from the hospital for patients at high risk of readmission.

“Rapid Response Nurses complement the care provided by our care coordinators and community nurses,” said Jacqueline Redmond, CEO of the South East CCAC. “Our aim is to help people stay at home safely and independently by providing access to the clinical care and community supports that patients need. Rapid Response Nurses have an important role to play in helping us achieve that goal.”

Redmond said the nurses will assess high-risk patients once they’ve returned home to catch deteriorating symptoms or complications and prevent readmission to hospital by connecting a patient with a primary care provider, providing medication review and ensuring patient’s receive appropriate home supports as quickly as possible to help them stay at home safely.

The program, she said, is based on research which shows that making a successful transition from hospital to home is dependent on a few critical factors and early interventions.

“Rapid Response Nurses will help patients understand their illness and how to take prescribed medications, arrange for follow-up medical appointments or tests and connect with their primary care providers, ensuring everyone has necessary information about each step of the patients’ journey.

“It’s really a visit to stabilize and transition patients at home and link them with primary care. That includes ensuring that patients are coping well on their own, understand the hospital discharge plan including medication they should be taking and how and when to take it,” says Redmond. “The goal is to help people make the transition home safely. It is anticipated that patients will receive the knowledge they need to understand their illness and their part in managing it, as well as the necessary services in place to stay at home safely and independently.”

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  1. Wolf Braun says:

    Dayton asks: “Point being…is it a good idea to continue donating to OUR hospital or should donations be directed towards P.O.O.C.H ?”

    For the moment Dayton, you and your group should continue to support the Hospital Foundation. They still have important work that needs to be done.

    Right now the P.O.O.C.H. committee is working on a business plan in preparation for a second meeting with the Minister of Health and her staff. This work is going to take time and will eventually require some additional fund raising… above what was accomplished with our trip to Queen’s Park on April 17th.

    We know we can count on people to do fund raising when the time and need is there. I wish I could tell you “when” but it’s now up to the Minister to make the time for us. In the meantime, we are also working on putting some heat on the Minister, the Premier as well as the Cabinet.

    Hang in there Dayton. And if you have any questions or suggestions that will help P.O.O.C.H. save our hospital just email committee members Dave Gray, Betsy Sinclair, Al Reimers, Leo Finnegan or myself. My email is

  2. Marnie says:

    A few years ago it would have been hard to imagine that our hospital would become little more than a first-aid station. The county has changed dramatically in recent years and not for the better. A self-sufficient rural community is rapidly becoming a shadow of its former self. Sad that two excellent physicians are moving on because of the proposed cuts to our hospital. It is likely that others will follow and who can blame them? The county is now one big vineyard with a new cultural event every 20 minutes but no hospital and a downtown with its share of empty stores.

  3. Doris Lane says:

    Two doctors leaving already–you can’t blame them butI have been told that some people cannot get a doctor know–who is ging to look after all the patients the doctors leave behind??
    I think I our health care here will just get down to the theory–take 2 aspirins and go to bed.
    We did not want a first aid station here—we wanted a hospital and all of us old foks worked hard so we could have one

  4. Marnie says:

    My cousin in Fort Erie has been an active member of the WHA there for many years. When their hospital was downsized, she and other suxiliary members watched helplessly as the equipment they had worked so hard to buy was carted off to other area hospitals. I will not donate anything further to PECMH until it is known what will happen with our hospital. I support the auxiliary members who work so hard to raise funds for it but as long as there is the chance that what we pay for locally will go outside our county I’m not willing to contribute anything.

  5. Dayton Johnson says:

    As one spokesperson for our little music group the “Shirt-tail Cuzins” we donated over $10,000 in 5-6 years to our Picton Hospital from shows we put on in the Milford “Shed” and other places. Gradually we began to realize that donations did not appear to be being used locally.The last few years we opted to spread the funds in the community to various organizations.
    Point being…is it a good idea to continue donating to OUR hospital or should donations be directed towards P.O.O.C.H ?

  6. Wolf Braun says:

    Thanks Marnie. P.O.O.C.H. committee members are working hard on saving our hospital. But, there is still a lot of work ahead of us that involves every person in The County.

    The article above states: “Rapid Response Nurses are to care for patients with complicated health needs in consultation with CCAC care coordinators, community nurses and other community health providers by making a home visit within the first 24 hours after the patient is discharged home from the hospital for patients at high risk of readmission.”

    This statement begs more questions… with no answers.

    How is someone evaluated as “high risk of readmission”?

    Why would you discharge someone if the are assessed as high risk?

    If a person is at high risk, why wait 24hrs. How was the 24hrs determined to be the benchmark?

    What is discharge number for PECMH ? How will 2 nurses cover that number? How was it determined that 2 nurses would be assigned to Hastings and PEC ?

    … Wolf

  7. Marnie says:

    An excellent summary of the current situation, Wolf. It is disrespectful to suggest that seniors are clogging the system. Many of these people donated to build our hospital. Who can blame the doctors for leaving? There will soon be few opportunities for them here. Our family once relied on home care services to help care for an elderly relative. It was unsatisfactory in many ways and we finally hired a private individual to provide some of the services. The services of travelling nurses are not going to take the place of proper hospital care. we deserve better than this.

  8. Wolf Braun says:

    Two Prince Edward County doctors have notified their patients that they will be leaving The County. They no longer have confidence that they can treat their patients safely at PECMH. It is only the beginning.

    ” No man’s life, liberty or property is safe while the legislature is in session.” Mark Twain (1866).

    The Prince Edward County Memorial Hospital is a prime example of the above quote by Mark Twain. There is no use in recounting our losses since amalgamation in 1998/99. We all know what has happened and the imminent loss of two of our resident doctors only adds to our discouragement and disillusionment with the current system of health care under QHC.

    The distribution of our health care dollars has become a shell game where hospital budgets are balanced at the expense of patients, services and staff. It’s a simple game really, get the patients out of the hospital quickly and dump their care on community health services that are woefully inadequate to the task with which they have been charged. The dollar value of their care then gets entered on a new and different balance sheet.

    The ability of Home Care Services to meet the demand is at best questionable. The race to demit high risk patients to Home Care even with a travelling nurse only ensures that the patient arrives at home alive. It could then be 24 hours before any further assistance is given. This is not best practices.

    Statements from health care authorities continue to categorize chronic care patients as being responsible for “clogging the system” and the main contributing reason why hospitals can’t balance their budgets. “Clogging the system” is an ugly statement aimed at our seniors, as if they were no more than garbage stuck in a drain. But then lack of sensitivity on health care issues is nothing new.

    P.O.O.C.H. is a local initiative. Our only purpose and reason to exist is to “Take Back Our Hospital” and to that end we are preparing plans to make this monumental task both feasible and financially responsible. But these plans take time, research, and most importantly support from you the patrons of our hospital. We are working steadily toward our goal; that being a second meeting with the Minister of Health Deb. Matthews and the preparation/ presentation of our business plan. We will fulfill our commitment to you the patrons of our hospital.

  9. Jan says:

    Again in response to Jack’s comments, I would like to question why we would not still receive our provincial/federal entitlement of health care grants? Since we would not be
    top heavy with bureaucratic waste producers and not having to fund a public relations firm to offer press releases to the the newspapers, this savings would be a tremendous help to our little local hospital. So with our share of the government funding that has been mainly directed to the Belleville hospital and the efforts of the Prince Edward County Hospital Foundation as well as numerous fund raising that could take place, I see no need to increase our taxes anymore than they already are being raised. Possibly, a surcharge on homes valued at over $500,000 could be considered. Obviously if you can afford a home valued at over half a million dollars, a few extra dollars tacked onto your tax bill should not be much of a burden!!

  10. Jack says:

    Jan, I certainly agree with your comment regarding QHC bureaucracy, I believe our best option is to opt out of this umbrella group if it is legally possible and we would not lose our provincial funding.One option might be to put a hospital flat surcharge or percentage of assessment on our property taxes to go directly to the hospital budget. I know this would not be popular but could be voted on at municipal election time. If we want our own hospital we are going to have to pay for it.

  11. Marnie says:

    Some new-fangled idea – bloat the system with bureuacrats and cut the front-line workers. Push sick people out of the hospital with a travelling nurse while a top heavy administration empire builds.

  12. Doris Lane says:

    Cut out the high paying jobs to people who never see a patient.
    A fee to everyone whogoes to the doctors office.
    Everyone can afford a small fee or else they wouldn’t pullout the cigs when they get outside
    how much of the health care dollar goes directly to patient care–how much to waste?

  13. Jan says:

    In response to Jack, if we cut the fat from the budget, it would not be consuming
    80% of the budget by 2030! It is high time that the LYNS or whatever those initials are and
    the health care bureaucracy are eliminated and or slashed to the bare bones. Why for instance are we paying for media people to give “press releases” for QHC. Why can’t the overpaid CEO speak directly to the media and answer any questions put to her? I would love the job of house cleaning the excess highly paid baggage at Belleville General Hospital! How many bureaucrats at QHC are losing their jobs to solve the present financial crisis?? Let’s get rid of a few lab technicians and save the bureaucrats’ jobs. If we cut back on lab tests, more patients will die and fewer beds will be needed!! This is a great
    solution to the financial crisis!! Read the headlines to the Intelligencer! The CEO appears to be trying to haul the unions into her web.

  14. Jack says:

    Doris: New fangled ideas must be tried or our Grandchildren will be living in a 3rd. World country. At the present time 40 percent of the provincial budget goes to health care if we continue down the same road it is estimated that it will be 80 percent of the budget by year 2030. Must get back to the hockey game.

  15. Marnie says:

    Sorry Jack but I remember a time when doctors worked longer and harder for a lot less money and raised their families at the same time. Your doctor may make house calls but that is the exception not the rule. Doctors seem to have a lot more holiday time than they once did. Try and find one during Easter break. There was a time when doctors had a cover system and took turns being on call on Wednesday afternoons and weekends. They saw patients in their offices or made home visits when on call. Now they pack everyone off to the ER. That’s why it’s so crowded.

    There was a time when an office visit took longer than the ten minutes or so most of us are allotted today.

    I’m with Doris. When I die I want to do it in a hospital, not at home with a travelling nurse who may not arrive before I depart.

  16. Doris Lane says:

    I have spent many hours in my life working to build up our hopital. when it is time for me to die I want to go to the hospital to be looked after. I do not want a home care nurse or a hospice. for the most part I want a quiet place as isolated as possible.
    Lets hope I go quickly sometime so I do not have to put up with the new fangled ideas

  17. Jack says:

    Marnie, I take exception to your suggestion that local Doctors are lazy because they don’t work week-ends and evenings, they need time away from their work as much as anyone else and by the way our family physician makes home visits.

  18. Marnie says:

    If a patient is at high risk for readmission Jack it cannot be much comfort to them or their families to be sent home with a travelling nurse to take the place of full hospital services. We should not feel guilty about occupying a bed in the hospital that we helped to fund. Today, many people go to the ER often because their family doctors send them there rather than work them into their schedules. They are not willing to work evenings or weekends as physicians doctors once did if required. Nobody today sits down at the ER at the bottom of a triage list because they have a hangnail Jack. People go there because they are sick and it’s the only way to see a doctor. We should not be placed on a guilt trip because we feel that sick people belong in a hospital.

  19. Jack says:

    I,am sure if you talk to the discharge nurse co-ordinator at Picton Hospital that know one is discharged if they require 24hr. Nursing care or some type of special medical equipment is needed for their treatment. We are at present receiving home care and although it is not perfect, it is adequate and free’s up a bed at our local hospital for someone more seriously ill. We the taxpayer are the people funding the Heath system and if something will save money why not try it. What I would like to see is a small surcharge for these people who run to Emergency with a hang-nail etc. My daughter lives in New Zealand which has a universal Heath care system but anyone over 6 yrs. old must pay a $38 fee to see a Doctor and if they are diagnosed with a legitimate illness the fee is reimbursed.

  20. Marnie says:

    The idea that visiting nurses can make the difference for patients who are at high risk for readmission is feeble. How much time can they realistically spend with these individuals? Sick people belong in the hospital. More and more efforts are being made to convince us that we don’t really need a hospital. Are we going back to the days when operations were performed on the kitchen table? Why not a series of books titled Diagnoses for Dummies, Do-It-Yourself Home Tests and Surgery for Beginners?

  21. Susan Rose says:

    exactly Jann well put!!

  22. Jan says:

    Just another step in getting rid of Picton hospital!! These travelling nurses cannot replace good hospital care that is needed until the person is well enough to go home!! Patients being sent home with the anticipation that they will likely need to be readmitted can certainly cause stress and probably contribute to them being readmitted! Two travelling nurses are not the answer to our health care situation in Prince Edward County. Canada is operating more and more like a third world country when it comes to health care. We need to get our priorities sorted out. Our health care system is more important than all the “artsy” frills in society today!

  23. Susan Rose says:

    Where did this idea come from? Sounds like one of those ‘cost savers’ again…if a patient, I would insist at staying in the hospital until well enough to go home…this seems rather scarey to me. Also sounds like too many arrangements that no doubt wouldn’t go smoothly, and who needs more headaches when you are ill to begin with..

  24. Marnie says:

    How can it be in the patient’s best interest to be discharged from hospital when he or she is at high risk of re-admission? Chances are a lot of these people will be readmitted and where are the savings? People this ill belong in the hospital. A terminally ill friend of mine was discharged to a nursing home some time ago. He paid for a month’s care and lasted less than 24 hours before being rushed back to the ER. He was readmitted and remained in hospital until he died. In addition to all of his health problems he had the added burden of trying to recover the month’s rent he had paid to the retirement home. Sick people do not deserve to be sent off to their homes while they are considered as being at high risk for re-admission,eveb if there are nurses who will check in.

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