Nurse Led Outreach Team Helping People Avoid Visits to Hospital

Thunder Bay Regional Health Sciences Centre’s Nurse Led Outreach Team
Thunder Bay Regional Health Sciences Centre’s Nurse Led Outreach Team

Just over a dozen Nurse Led Outreach teams exist in Ontario, and one of the most unique of these is at Thunder Bay Regional Health Sciences Centre. Since 2009, the team has supported many clients to manage medical conditions outside the hospital, helping them to avoid Emergency Department visits and decrease the need for a Hospital stay.

Thanks to funding from the Northwest Local Health Integration Network (LHIN), the Nurse Led Outreach Team began with one nurse practitioner and a nurse visiting long-term care facilities throughout the city. There was also a nurse working in the Hospital to support patients admitted from long-term care facilities, and liaise between them, the nurse practitioner, and the facilities.

After the team’s first year, visits to the Emergency Department from long-term care facilities decreased by an impressive 19%! The program gradually grew in both size and scope, and now includes six Nurse Practitioners and 1.5 Nurses serving all long-term care facilities in Thunder Bay, as well as retirement homes and assisted living facilities.

Patients and their family members are tremendously appreciative of the difference the Nurse Led Outreach Team makes. Because of their efforts:

  • More people are treated at home, avoiding transfers from the facilities to the Emergency Department or Hospital;
  • Fewer people are admitted to the Hospital for conditions which can be treated in home;
  • People who live in the facilities and are admitted to the Hospital return home sooner with appropriate support by the Team.

In an average year, the team’s Nurse Practitioners see over 2,000 residents in retirement homes and the same amount in seniors’ supportive housing. Over 10,000 residents are seen on average in one year in long-term care, with less than 300 of the total population of long-term care residents admitted to Hospital during that same time period.

Our Hospital’s Nurse Led Outreach Team has one of the highest ratios of Nurse Practitioners in their team. The Nurse Practitioners can provide advanced assessment diagnosis, treatment and management of illness. They can order a range of diagnostic tests, prescribe medications and can intervene and treat urgent medical conditions. While they don’t replace the role of the primary care provider, the Nurse Practitioners work alongside other members of the health care team. That may include partners at the Community Care Access Centre, St. Joseph’s Care Group, Diabetes Health Thunder Bay, community pharmacies and other programs at the Hospital.