Alternate Level of Care (ALC) is a designation to identify patients in-hospital who no longer require acute care but are unable to transition to a more appropriate setting due to capacity issues, complex health and social needs and various other reasons. High ALC rates are a symptom of a system wide problem that requires all health sectors to work together.
Millennium Trail Manor Long-Term Care Home is using a preventative approach to ALC by reducing the number residents who visit the emergency department (ED), thus avoiding the risk of residents experiencing lengthy hospital admissions, potentially losing their long-term care bed, and being designated ALC.
To learn more about how they have significantly reduced ED visits, Health Quality Ontario had a chance to catch up with Lori Turcotte, Administrator, Diane Garrett, Director of Care, Michele Hough, Assistant Director of Care, Sandra Ashcroft, Assistant Director of Care and Lois Barlow, Nurse Practitioner at Millennium Trail Manor.
From left to right: Lois Barlow, Nurse Practitioner, Sandra Ashcroft, Assistant Director of Care, Michele Hough, Assistant Director of Care, Diane Garrett, Director of Care, Lori Turcotte, Administrator
Can you share what led to your significant improvement in reducing resident ED visits?
The biggest impact on our ED visit rates has been the addition of a Nurse Practitioner (NP) to our health care team. In 2015, we submitted a proposal to the Hamilton Niagara Haldimand Brant LHIN to hire a full-time NP, Lois Barlow. We outlined our current performance across a number of quality indicators and made a case for hiring a NP to help improve our resident care.
Previous to hiring Lois, NPs were available to provide support, but they travelled to various sites within our region and were not dedicated solely to our facility. Having full-time support has made the difference.
In addition to our NP’s expertise, we have three Critical Care trained nurses on our management team who can manage residents with more complex health needs such as PICC lines and IVs. This helps expedite residents’ return to the home after a hospital stay.
What is the scope of the NP role?
Much of our NP’s role is focused on clinical care. She works collaboratively with our three physicians, nurses, other staff members, and families to address residents’ health issues in a proactive and timely manner.Building these relationships was key. Now, staff and family members feel comfortable consulting with our NP about resident issues, which creates efficiency in care.
The NP also spends a significant time educating residents and families about the pros and cons of ER visits.
Many families want to send their loved ones to the ER because they believe that is where they will receive the most appropriate care, but this may not always be the case.
We recognize that the hospital, particularly a busy ED, is not always the most appropriate place for residents who require turning, positioning, incontinence care and total assistance for activities of daily living. Residents are at risk of MRSA, altered skin integrity, increased confusion and responsive behaviour when they transfer to hospital. As a result, our goal is to educate residents and families about the expertise and services offered in the home that may be more appropriate than an ER visit.
Our nursing management team (which includes the NP, DOC and ADOCs) provides resident education upon admission, at care conferences and at resident and family council meetings. We use Choosing Wisely Canada’s resources to explain alternatives to hospitalization. The Nursing Management team completes health care treatment plans with residents that outline their wishes around hospital admissions. This resource was developed using the Advocacy Centre for the Elderly (ACE) publications.
How do you work with your local hospital to reduce ER visits?
Our NP works closely with our local hospital, Niagara Health System (NHS). When it’s necessary to send a resident to the ED, our NP provides information to the hospital about what treatments and medications have already been administered and what tests were done to help the ED assess a resident more efficiently.
We are part of a Transfer Project Committee with NHS with the goal of improving the resident transfer process back to our home. The project includes developing a transfer discharge sheet with pertinent information our home needs when a resident returns from the hospital. We’re also able to use Clinical Connect, to access residents’ tests, medications and medical status and we communicate regularly with the hospital’s discharge planners and clinical manager to facilitate transfers back to our home.
Our NP and Medical Director have conducted Choosing Wisely sessions for NHS’s ED nurses, physicians and other hospital staff to educate them on the challenges of caring for residents in the ED.
We all want to avoid or limit the amount of time residents spend in the ED to lessen the burden on the hospital system. Working closely with the hospital is key to making this happen.
Did you face any challenges on-boarding the NP?
While developing the proposal to hire a new NP, we had a number of meetings with our Medical Director and physicians to ensure they were comfortable with the NP’s job scope and description. We discussed how the NP would work with the health care team to improve care.
Initially, we had to go through a phase of relationship building and developing trust. We laid the ground rules and frameworks early and looked at the Ministry of Health’s recommendations for the NP role to help develop a clear understanding around roles and responsibilities.
Over time, the trust has grown and there is a great deal of benefit of having a NP with intimate knowledge of all our residents. She is able to bridge the gaps in care and attend to less urgent issues so that the physicians can focus on more complex residents.
What advice would you give to other LTC homes looking to reduce their ED visit rate?
If possible, secure funding for a NP and work closely with your local hospital. If you don’t already have access to real-time data through an EMR like Clinical Connect, this is also very highly recommended to support resident transfers back from the hospital.
Do you work on the ALC issue in your Long-Term Care Home? Write a comment or questions below, or reach out to Lori Turcotte, on Quorum.
You may be interested in our quality improvement stories featuring the work of long-term care homes across Ontario.