Early Interventions Improve Care for At-Risk Seniors

Service demand is growing for senior patients. In addition to requiring health care more often, their needs are different from the general population. A new program at Thunder Bay Regional Health Sciences Centre supports senior patients to receive the right care, at the right time, and by the right provider.

“My family recently experienced the Hospital’s Geriatric Program when our Step-Dad was diagnosed with dementia. He was assessed early in his admission to the Emergency Department and was monitored closely throughout his stay by the Geriatric Care Coordinator,” said a family member. “We had been struggling at home with his changing care needs but the team listened to us and guided his care accordingly, keeping us informed every step of the way. We’re very impressed by the level of care our Dad received and are hopeful, that as a result, he can remain healthier and at home.”

Beginning in the Emergency Department, the Program aims to streamline the assessment process of at-risk seniors through collaboration with internal and external partners, consultation with geriatricians, physicians, St. Joseph’s Care Group, and the North West LHIN’s Home and Community Care.

“When at-risk or frail senior patients aged 65 years and older arrive at our Hospital, they are assessed using standardized tools. A Geriatric Care Coordinator can identify potential geriatric health concerns and facilitate the appropriate care plan,” said Ron Turner, Senior Director of Patient Care and Health Professions. “By providing senior friendly care early, we can achieve improved continuity of care, enhanced patient experiences and better outcomes.”

During assessment, the Geriatric Care Coordinator looks for signs of geriatric syndromes, including mobility issues, weakness, frailty, functional decline, pain, cognitive impairment, dementia, delirium, and other risk factors often associated with seniors. The Geriatric Care Coordinator also supports discharges for patients who do not require acute care in a hospital setting; and works with community partners to provide a smooth transition to home or other programs and services that would best address their needs.

“Research has shown that prolonged hospital stays can lead to further complications, particularly for senior patients,” said Turner. “Having someone on the team who is directly responsible for organizing their care needs ensures that patients will get the appropriate level of care they need, in a safe way and without undo delays.”

So far, the program has yielded successful results. The average length of stay for senior patients has decreased and continues to do so as the program progresses. Patient experiences have been enhanced and families and caregivers have expressed content with their level of inclusion in the care plans of their loved one and the ongoing support provided after discharge.

To learn more about our Hospital’s commitment to seniors’ health, visit www.tbrhsc.net.