We're finding more ways of providing services and support before people reach the point of needing hospital care by targeting high risk groups.
Across the country – and in fact all over the world – conversations amongst health care leaders are tuned towards this concept of “shift” we talk about so much in Fraser Health. When we talk about the shift, we are talking about moving away from a system that relies heavily on hospitals and towards a system that promotes health and wellness, prevention and management. Refining our use of hospitals and expanding community services are two ways to create a more sustainable system that better supports the health needs of our communities and citizens. Fraser Health is well positioned to make this shift a reality. Our vision Better health. Best in health care. has long stood for our organizational commitment to help people be well, stay well, get well, or manage better and when they are sick or injured, to deliver the very best care we can.
Our Executive team members are committed to making decisions and organizing their portfolios to best support our efforts. I’d like to introduce them and let them tell you how they are supporting Fraser Health’s vision of Better health. Best in health care.
Our 12 regional hospitals are a crucial component of our health care system, but they aren’t the only pieces of the puzzle. We recognize that while acute care has a role to play when our patients need specialized care, for others community or home care better serves their needs and facilitates their recovery.
I’d like to introduce you to one of my newest Executive members: Laurie Leith, Vice President, Community Hospitals and Programs.
Much of what we’re doing now is to find more ways of providing services and support before people reach the point of needing hospital care. This is most effective when we target higher risk groups such as frail seniors or people with mental health or substance use challenges.
Under the guidance of the Ministry of Health, we’re working in partnership with the Divisions of Family Practice to create what are called primary care homes, starting with the areas of Fraser Northwest, Abbotsford, Mission and Surrey. These will be a network of family physician practices, each using a team-based approach (with other disciplines such as nursing or allied health professionals) to deliver a full range of patient-centred services, including specialized services for those higher-risk populations. We’re working with GPs and other health professionals, along with community supports, and improving communications with the health authority, allowing for better care management that is proactive rather than reactive.
Expanding our successful Home First strategy, we’re identifying people who can safely transfer from the hospital back to their home with enhanced supports. Often they’re waiting for a residential care bed, but it’s more comfortable and safer for them to wait at home. With those added supports, sometimes people do so well they are able to defer their entry into residential care. And if you want to help people stay at home longer, how do you support their caregivers? Increasing adult day programs and augmenting home support are two examples. As well, managing dementia is another particular challenge and we need to identify innovative strategies to allow for 24/7 cost-effective care.
When someone’s home is in residential care, we want to keep them as healthy as possible and avoid hospital admissions. The PREVIEW screening tool allows care aides to play a crucial role in the identification of people who might be in the early stages of pneumonia, dehydration, congestive heart failure or urinary tract infections, so that treatment can begin and an Emergency visit can be avoided. In a pilot at four residential care homes, results showed a 71 per cent reduction in transfers to the Emergency Department. The tool has now been introduced into additional facilities with plans for further expansion.
We’re partners in other projects that aim to keep people healthy in the community. The Community Actions and Resources Empowering Seniors (CARES) in Maple Ridge partners seniors, their primary care provider, and volunteers to provide wellness plans and coaching, helping seniors stay healthy and avoid frailty.
And the Langley Seniors LINC (Langley Integrated Network of Care) initiative provides team-based care for seniors who would most benefit from services being wrapped around them, providing longitudinal care delivered by a physician, geriatrician, nurse practitioner, registered nurse, licensed practical nurse, occupational therapist, physiotherapist, pharmacist, social worker and spiritual health practitioner.
I have been part of the Fraser Health family for just a few short months so far but I’m heartened by our current successes and strategies, and I see great opportunities for others, including virtual care. Telehealth, home health monitoring, a patient portal for people to have greater access to their records, and self-monitoring apps, for example, can bring expert care to people where they are, and allow for improved information sharing.
I look forward to continuing to work with my dedicated colleagues on that and in other ways to provide the kind of care that helps people stay healthier, longer.