In 2015, family doctors with the Fraser Northwest Division of Family Practice identified a need for more support and services for frail elderly patients, many of whom were presenting in the emergency room with issues that could have been managed at home. The division hired a nurse—Nurse Debbie—to support family doctors in caring for these homebound frail elderly patients. This innovative role extended primary care services into patients’ homes, ensuring they could receive the care they needed quickly before health issues could develop further. 

This type of team-based care model has been identified as a top priority in improving care for patients around the province.[1] Health care teams are being built in patient medical homes within family practices, through primary care networks in communities, and within urgent primary care centres. These teams can take several forms and can comprise a wide array of allied health providers, including nurse practitioners, nurses, physiotherapists, dietitians, and social workers. 

The home nursing team-based care model built into the Nurse Debbie initiative was so successful that the service was expanded by the Fraser Health Authority, becoming the Fraser Health Primary and Community Care Nursing Program. 

Grassroots beginnings

The original Nurse Debbie began the process of supporting Fraser Northwest family doctors by meeting with them to review their patient panels and identify suitable patients. Then, under the direction of each doctor (as an extension of the doctor’s office itself), Debbie began providing care for frail elderly patients in their homes, eventually seeing an average of seven patients per day. 

Between January and December 2016, Nurse Debbie saw 469 patients in their homes. This in-home primary care support prevented more than 500 patient visits to the ER and thousands of patient bed days, saving an estimated $3.1 million in health care costs.[2] 

Inspired by the results being achieved by the Nurse Debbie initiative in Fraser Northwest communities, Fraser Health created the Fraser Health Primary and Community Care Nursing Program. They hired Nurse Debbie to run the expanded program, as well as two other nurses to provide the same services in the region. The health authority also established a support team to streamline assessments and paperwork and create more efficient connections to patient supports. 

Fraser Health and divisions also worked with GP offices to ensure that nurses are able to access physicians’ EMRs in order to share patient information—a key component in ensuring the program’s success. Nurses are now able to send messages to physicians within their EMR about the care they’ve provided, and doctors can stay up-to-date on their patients’ conditions while their patients stay safely at home. 

In addition to Fraser Northwest, three other divisions of family practice have now implemented the Fraser Health Primary and Community Care Nursing Program.

Chilliwack (including Agassiz-Harrison and Hope)

Twenty RN/LPN teams are now working in pairs across Chilliwack-area communities. These teams collaborate with family physicians or nurse practitioners to support patients with advanced health care needs, and arrange support from occupational therapists, physiotherapists, and social workers as needed. Over a 10-month period, the work of the first team resulted in an estimated 19% reduction in ER visits and a 21% reduction in inpatient days.

Ridge Meadows

Twelve primary and community care nurses are now providing care in alignment with all GP offices in Maple Ridge/Pitt Meadows. An evaluation of the initial 8-month Primary and Community Care Nurse pilot program showed a reduction in ER visits and highlighted a number of positive patient stories and experiences. Providers reported that the model improves interconnectedness and accessibility of services for patients and enables them to be seen in a more timely fashion. 

Surrey–North Delta

In 2018, the division partnered with Fraser Health’s Home Health Program to deploy a primary and community care nursing model across the community. Through the program, nurses partner with family physicians to better support their most frail and complex senior patients, assess their safety, and assist with acute medical needs. Nurses also guide patients to self-manage their conditions and connect them to a team of allied health professionals including occupational therapists, physiotherapists, dietitians, and social workers, as well as other resources in the community. 

Region-wide success

A 3-year analysis of the Fraser Health Primary and Community Care Nursing program followed 1071 patients for between 6 months and 3 years.[3] The analysis showed that 596 ED visits were avoided and 15 464 bed days were saved between 2016 and 2019.[3] 

There are now 29 nurses working in the Fraser Health region extending primary care services into the homes of elderly residents. Nurses see five to seven patients per day, and patients can call them directly or be referred by their family physician. Through the Primary and Community Care Nursing Program, Fraser Northwest’s grassroots Nurse Debbie initiative lives on—improving quality of care and providing peace of mind for patients and providers alike. 

For more information on team-based care, patient medical homes, and primary care networks, visit www.gpscbc.ca.  
—Afsaneh Moradi
Director, Community Partnership and Integration, Community Practice, Quality and Integration

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This article is the opinion of the GPSC and has not been peer reviewed by the BCMJ Editorial Board.

References

1.    General Practice Services Committee. What we do: System change. Team-based care. Accessed 4 July 2019. www.gpscbc.ca/what-we-do/system-change/team-based-care.

2.    General Practice Services Committee. Our impact: Team-based care. Care for frail seniors: How one nurse changed the system. Accessed 18 July 2019. www.gpscbc.ca/our-impact/team-based-care/care-frail-seniors-how-one-nurse-changed-system.

3.    Integrated Analytics. PCN – Model TC/NW communities Royal Columbian and Eagle Ridge. Acute care utilization evaluations. Accessed 18 July 2019. https://bit.ly/30G6oAo.