Caring for people in the right setting is a priority. One of the ways we are helping achieve better outcomes for clients by supporting them in their home community is through our primary and community care nurses.
The health care system is changing. People want health care that is accessible, coordinated and understandable – no matter where or by whom they are cared for. In our Transforming the Health Care System series, we share the stories of how we are changing the system and achieving positive outcomes for people and health care providers in our communities.
Caring for people in the right setting is a priority in Fraser Health not a philosophy.
One of the ways we are helping achieve better outcomes for clients by supporting them in their home community is through our primary and community care nurses. These on-the-go health care heroes work in the community, often in close partnership with family practitioners to care for people who are home-bound. This gives peace of mind to physicians having someone in the field they can call to check on their patients, which often prevents them having to visit the Emergency Department.
Primary and community care nurses are the agents of team-based care, ensuring their clients have what they need in the community and keeping them thriving at home.
As part of our work to transform our community health care system, each community in Fraser Health is redesigning primary and community care services to create teams to work more closely with clients, their family practitioners and other care providers. Following the success of this work to date, a regional job description was created to spread the model to other communities.
Meet Terry Aiello, a primary and community care nurse in the Maple Ridge/ Pitt Meadows community.
Terry has been a nurse for more than 25 years and she is fulfilling her lifelong childhood dream. She has been with Fraser Health for 14 years and is skilled in the specialties of Emergency Medicine, as well as Maternity.
Terry enjoys learning new skills and learning about new ways to improve client care. When the opportunity came up to work in Home Health, she knew it was a good fit for her, knowing the positive impact community-based care can have on clients.
“I love being able to be there for people when they need somebody.” says Terry. “It makes a positive impact on clients to have one person that they can call who can come out and deal with whatever is going on for them.”
Terry enjoys getting to the root of what her clients and families need and ensures that conversations engage everyone involved.
A highlight of this role for Terry is helping clients discover what services are available to them in the community.
Some of these supports include referrals to day programs, seniors’ wellness groups, transportation and meal support programs, and Lifeline, a Personal Emergency Response Service that ensures assistance 24 hours a day, 7 days a week.
What is most rewarding for Terry in this role is getting to know her clients better. “One of the things I’ve noticed is the difference you can make to clients when you see them in their home. What you see in the hospital is different at home. You get a real sense of what they are about when they are at home, how they live and having that is key to knowing who they are.”
If there are any challenges with being a mobile nurse, they don’t discourage Terry from her passion for this role. “There are times when the technology may not work as well as others but this is being worked on.” In fact, Terry is eager for more people to come on board with this model of care. “There are better outcomes when a patient can stay at home; they can thrive.”
People agree. Clients frequently remark that Terry has helped motivate them to be more active in their daily routine, and families comment that they feel more at ease knowing that home-based care is available.
This model of care shows that we can support our clients and help prevent Emergency Department visits. Our initial Rapid Response Nurse Pilot data showed that out of 42 clients assessed and seen, Terry was able to prevent an Emergency Department visit for 38 of those clients. Of those 38 prevented visits, seven of those clients had already been to the Emergency Department five or more times during the last year. This pilot has further influenced the new Primary and Community Care Nurse model.
What Terry does matters – to clients, to families and to how we are shaping health care.
How are you transforming the health care system? Tell us in the comments.