Primary Health Care Update: Senior’s House Calls Program, Connecting Time to Care

Home / Physicians News / Primary Health Care Update: Senior’s House Calls Program, Connecting Time to Care

Primary Health Care Update: Senior’s House Calls Program, Connecting Time to Care

06-Dec-2016

Senior’s House Calls Program

Kathy Engen, Advanced Care Paramedic, Seniors House Calls, documenting in EMR from car and talking to a client.

Over the past year Primary Health Care Networks have been developing a community based “Senior’s House Calls” program to provide medical assessment and treatment services to frail elderly clients in the comfort of their own home.  Our “Senior’s House Calls” providers include Nurse Practitioners, Community Paramedics and a Pharmacist who work in collaboration with community care teams, family physicians and hospital care teams to meet the needs of our frail seniors living in community.  We are happy to report our program trial period has been successful to date.  Our trial period has been extended and expanded for another year in order to support more home based seniors care.  To date we have served more than 200 frail seniors preventing ER visits and subsequent acute admissions and we are ready to increase and expand our referrals.

 

Brandy Karton, Advanced Care Paramedic, Seniors House Calls, performing phlebotomy in home of client.

Program goal:  to be a responsive 7 day a week service supporting frail seniors in community by providing medical assessments and treatments in their home.  This improves our clients access to services, meets their needs in their own home and working to prevent the need to access the Emergency Department and subsequent hospital admissions. 

Who we serve:  frail clients (primarily seniors) who are homebound or have great difficulty leaving their home to access medical care services.  These clients often have family physicians however are unable to access care due to limiting mobility, dementia challenges, limited family supports and/or overall frailty.   Please note:  Senior’s House Calls Program clients need not be home care clients to access this service.

 

Jessica Heathcote, Advanced Care Paramedic, Seniors House Calls, reading med in home of client.
Jessica Heathcote, Advanced Care Paramedic, Seniors House Calls, reading med in home of client.

What do our services include:  in home medical assessments, interventions and treatments in collaboration with the clients family physician.  This includes in-home access to medical assessment, semi-urgent phlebotomy services, IV medications, medication assessments, short-term follow-up post-acute episode and system navigation supports to broader community care services such as home care, case management services etc.   (Examples of the top diagnoses and treatments to date include:  query pneumonia, acute dehydration, UTI, COPD, cellulitis, post hospital follow-ups).  Care summary notes are shared with the family doctor to ensure a collaborative approach to care and treatment. 

Who can refer?  Referrals to this program need to be initiated by a health care provider (family doctor, home care team member, acute care providers, hospitalists etc.).  Once a client is involved with our program, the client can access the team directly.

 

Jessica Heathcote, Advanced Care Paramedic, Seniors House Calls, completing wellness check in home of client.

How to refer:  Call 306-766-6280 and our team navigator will discuss with you the client needs and together work towards a care plan to meet that client’s needs. 

What’s coming next?  We are working collaboratively with our EMS partners to identify frail seniors who access EMS services and need further follow-up care in community.  As well we are starting process development to enable first dose of IV Antibiotics to be administered in community.  We hope to be able to provide these services in the coming months. 

Connecting to Care

Connecting to Care, a Hotspotting Project has been a provincially funded pilot project working with clients identified to have highly complex medical and social needs and have frequent admissions into our Emergency Departments and Acute In-Patient services.  Often our current system does not meet their needs adequately; therefore this team has been developed to provide a more compressive and holistic community based approach to support their needs. 

Our team of providers (community paramedic, RNs, and social workers) have worked successfully with many clients to support them in accessing appropriate service to better meet their needs and therefore to become more independent with their care, and achieve their health goals. 

What do our services include:  The Connecting to Care team provide both medical care, support and in-depth case management services which includes support for both medical care access and social supports. 

Who we serve:  Clients with highly complex medical and social needs who have very frequent encounters with our Acute Care services – both the Emergency Department and In-Patient admissions.  The team currently serves between 30-50 clients per month, always working to support positive patient outcomes, reduced dependency on acute care services and ultimately to graduate them to full independence. 

Program goal:  Support clients in a holistic and community based focus to assist them in meeting their needs thus reducing their need for acute care interventions.

Who can refer?  Referrals to this program need to be initiated by a health care provider (family doctor, home care team member, acute care providers, hospitalists etc.).  Once a client is involved with our program, the client can access the team directly.

How to refer:  Call 306-766-6280 and our team navigator will discuss with you the client needs and together work towards a care plan to meet that client’s needs. 

What’s coming Next?  This program is currently under evaluation by the Ministry of Health to determine future permanent funding.

Preliminary Program Results for the designated 12 month cohort sample of 16 patients:

 

Total Pre

Total Post

%diff

Inpatient visits

69

35

-49%

LOS

872

319

-63%

cost

 $      762,093

 $   294,746

-61%

ED visits

454

256

-44%

ED cost

 $      162,532

 $     91,648

-44%

Inpatient & ED Cost Combined

 $      924,625

 $   386,394

-58% 

More Connecting to Care information:

%3Ciframe%20width%3D%22560%22%20height%3D%22315%22%20src%3D%22https%3A%2F%2Fwww.youtube.com%2Fembed%2F3Bhct1B4Qyk%22%20frameborder%3D%220%22%20allowfullscreen%3E%3C%2Fiframe%3E