By Cecilia Nasmith/Today’s Northumberland
One year in, the work of the new Geriatric Assessment Team at Northumberland Hills Hospital is becoming known as a leading best practice. A presentation on this service was offered to the NHH board at its February meeting by team members Heather VanderMeer, Joanne Jury and Danielle Ferreira.
They work collaboratively with the emergency department team to identify qualifying patients – those aged 65 and over who are not medically unstable and who are not long-term-care patients – to perform complete, comprehensive assessments that result in care plans that support geriatric best practices and include comprehensive discharge plans and follow-up.
The GAT was launched at NHH a year ago as a Monday-through-Friday service working from 8 a.m. to 4 p.m. Within a month, they had expanded to seven days a week.
Admission avoidance is a key goal, and VanderMeer explained how it works. If a senior comes to emerg after a fall and the injury is not severe, the team steps in with mobility and function assessments to produce recommendations for such things as assistive devices, and home care and community services that can be accessed.
“We also meet with family to make sure it’s a very thorough plan,” VanderMeer said.
Therapy begins right in emerg “to decrease length of stay, to reduce admissions, to reduce ALC rates,” she listed, referring to the Alternative Level of Care beds that are tied up with non-acute cases that cannot be vacated until a workable discharge plan for that patient is in place.
“And most important – better outcomes,” she added.
Being available seven days a week has been one key to their success, as well as the wide-ranging network of partnerships – not only with such professionals as social workers and lab assistants, but also with such agencies as Port Hope’s Geriatric Assessment and Intervention Network and the Northumberland Paramedics’ Community Paramedicine Program. It all makes for a co-ordinated care approach.
Vandermeer listed the criteria for the service – being at least 65 years of age, having a history of falling, having mobility issues, being isolated or lonely, confusion or cognitive decline, having frailty or functional decline, stress or burn-out in the caregiver. The team has recently completed a screen tool called Identification of Seniors At Risk.
In its first year, the team reports a 77% diversion rate of those screened (or 478 admissions diverted). This includes a 10% reduction in admissions to ALC beds.
“We got them home safely, got them the right equipment, got them in the right place for their recovery,” VanderMeer said.
And for those admitted, length of stay declined from 8.56 days to 7.9.
Referrals to home and community care agencies has substantially increased.
The hope now is to make this a permanently funded team, along with improved communications with family members on preparing and planning, continued promotion of senior-friendly best practices, maintaining and strengthening community partnerships, and continued collaborative approach for early mobilization and delirium prevention.
Board member Pam Went commented on the conventional wisdom that, when a senior gets admitted to hospital, his or her chance of being readmitted rises dramatically.
Jury admitted that no discharge plan goes perfectly, so they put every effort into ensuring that the right piece of equipment is procured, the right services are securely arranged, the key connections are in place. These extra steps can make all the difference in preventing a readmission, Jury said.
“Every little piece that every member of the team does is really, really impactful to the outcome for that patient.”
As is the proactive follow-up, VanderMeer added, to ensure the right equipment has arrived or the Meals On Wheels have begun being delivered.
This program is attracting notice in other hospitals in the region, Vice-President of Integrated Care and Chief Nursing Executive Kate Zimmerman noted, and it is gaining regard as a leading best practice.
And at a time of “unprecedented volume,” President and Chief Executive Officer Susan Walsh added, “I can’t stress enough how amazing the team has been.”