Written by Mary Van Osch, RN, MSN, ENC, Clinical Nurse Specialist, Emergency Network

Our most vulnerable clients often present to emergency at high rates because they don’t know where else to go during a crisis.

Frequent users or ‘familiar faces’ account for approximately 12,000 Emergency Department visits in Fraser Health annually. On average, 67 percent present with mental health or substance use issues. Homelessness often adds to these challenges. It is clear that Emergency Departments aren’t always the best places for these patients.

If you look at ‘familiar faces’ in unfamiliar ways, you will see that these patients touch so many in the health care system. Across our hospitals and communities, Familiar Faces teams comprised of representatives of emergency, home health, mental health, primary care, BC Ambulance Services, and fire chiefs are collaborating to create locally developed and actioned solutions to make a meaningful impact.

Here is an example: Mr. R was homeless, struggled with substance misuse for many years and presented almost 100 times to Emergency Departments in 2016. He often needed to detox and left against medical advice before engaging in meaningful interventions.

During a recent hospital admission, Mr. R participated willingly in planning his care. The Royal Columbian Hospital and New Westminster Community team was able to assist him in securing housing and organized services to support him with taking his medication, having regular meals and paying his bills. He was connected with a primary care clinic and Community Mental Health Substance Use for follow-up. A care management plan was developed and included contacts from Mr. R’s new support system and suggestions of interpersonal approaches that were found to work best. This holistic approach to shared planning of care and community partnership helped meet Mr. R’s needs.

As Fraser Health works to enhance patient experience, we are strengthening hospital and community-based partnerships in order to support our vulnerable clients.

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