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Nurse Practitioner Kathy May (right) said much of the program’s success comes from collaborating with care-home staff.

When elderly long-term care residents have to go to the hospital, they’re vulnerable to complications, and their stays are often among the most expensive five percent.

To provide appropriate care for residents in the right place at the right time, The Ottawa Hospital brings the hospital to them through a nurse-led outreach team.

“Anything we can do to give residents an option to receive care at the home is good,” said Kathy May, one of three Nurse Practitioners (NPs) on the team. “They’re frail and they have complex health conditions.”

Started as a pilot project at The Ottawa Hospital in 2007, the team’s NPs work closely with care homes to support residents who might require emergency care. Based at the hospital, the team and supporting Emergency Department doctors now serve eight local, long-term care homes.

“NPs collaborate with the care teams and physicians in the care homes,” said Kelly Lumley-Leger, Advanced Practice Nurse and team manager.  “We provide enhanced assessments and deliver resident-centred, acute-care services in familiar surroundings. This collaboration is important because the care teams at the homes know their residents best.”

From 2012 to 2014, only 10 percent of residents seen by NPs were transferred to hospital – most received care at their own bedside. When they do go to the Emergency Department, they’re sent with an assessment to smooth the transition and provide emergency physicians with essential information. When the patients return to the care home, the NPs follow up to help implement the care plan and prevent readmission.

The team has been a hit with families, residents and the care teams, she said. “The families are so happy to have options before the Emergency Department.”

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