Clinical Pathways Support Frail Seniors’ Care in the Emergency

A new program has been introduced that begins in the Emergency Department (ED) at the Thunder Bay Regional Health Sciences Centre to speed up the assessment process of frail seniors, while ensuring that they receive the care and services they need.

Through collaboration with internal and external partners, consultation with geriatricians, ED physicians, St. Joseph’s Care Group, and the North West Community Care Access Centres (CCAC), the Frail Senior’s Pathway was developed to streamline access to care for the elderly.

“We recognize that when a frail senior patient presents in the Emergency Department, one of three things usually occurs: they have an acute illness that requires immediate admission to hospital; they have a condition that can be addressed in an inpatient rehabilitative setting; or they can be discharged home with necessary outpatient supports or services in place,” said Ron Turner, Senior Director of Patient Services. “With the help of funding from the NW LHIN, our group came together to create a process and a standardized assessment tool that would help determine our patients’ needs more effectively.”

Getting patients the right care at the right time is always important, and especially crucial in the case of our frail senior population. Turner said that by assessing patients earlier and making informed decisions about their care, they hope to avoid unnecessary admissions to hospital. Research has shown that prolonged hospital stays can lead to further complications, particularly for this patient group.

“An elderly person who is admitted to hospital can deteriorate alot faster than a younger patient. Without comprehensive rehabilitative services, there is the potential for our frail seniors to lose up to 5% of their functional ability per day while in hospital. As a result, discharge to home may no longer be possible, and an alternate level of care would be required.”

The new clinical pathway is supported by a Geriatric Care Coordinator. This nurse begins the patient assessment as quickly as possible and works with physicians and other clinicians to support the admission of patients, make referrals, and arrange transfers of care as needed. The Geriatric Care Coordinator coordinates with health care providers to ensure that services are in place before the patient is discharged from the Hospital.

“Having someone on the team who is directly responsible for organizing the care needs for these patients helps build confidence in the new process, and ensures that patients will get the appropriate level of care they need,” Turner said.

The standardized assessment has also strengthened the relationship with health care system partners. “With the standardized assessment, our community partners are confident that patients are being referred to them based on the type of care or services they provide.”

Program planning began in January 2017, and the clinical pathways have been trialed in the ED. Turner said that it’s still early, but so far results are promising.

“It’s really about having a collaborative approach to ensure that patients are assessed early and that the appropriate patient care can be coordinated and provided as quickly as possible.”