When Jia Ong heard that there was an opportunity to be part of a Nurse-Led Outreach Team (NLOT) for seniors in long-term care with Scarborough Health Network, she was intrigued. Having worked in a hospital intensive care unit and a family doctor’s office, she always wondered what happened to her patients when they left her care.
“I felt a sense of anxiety,” said Ong, who is a nurse practitioner. “For example, in the ICU, if a patient is no longer in critical condition they would leave from my care, and I wouldn’t know if they were being managed appropriately or not, and I don’t get any sort of feedback or closure.”
Instead, as a member of the NLOT, she can be there with her long-term care patients through the different stages of their health journey. “In this setting, I am able to continuously follow these residents.”
A province-wide initiative, NLOT’s are teams of nurses that visit local long-term care homes to support and improve residents’ medical care to avoid them having to go to the emergency room. Along with routine visits and responding to urgent needs, the nurses on these teams deliver specialized services — such as IV administration and wound care — and offer staff education.
“By providing this extra layer of support, it means that more residents are able to remain in their rooms instead of having to be sent to the hospital which can often be quite distressing for both them and their families,” said Ong.
While nursing may be most often associated with hospital settings, there are several programs where nurses are doing outreach work and meeting with patients directly in their homes, neighbourhoods and communities.
Lisa is a registered practical nurse with pc28Public Health (TPH) who works in the community to support tuberculosis (TB) clients through the course of their treatment. (TPH requested only her first name be used to protect the privacy of her patients since there is still a stigma associated with TB.)
“This type of support in the community is really valuable because treatments can be quite long — a minimum of six month to nine months to up to a year and sometimes even longer,” she said. After a diagnosis is confirmed, and the client is isolating at home, she tries to provide five-day support, visiting them regularly because they might feel overwhelmed with all the information bombarding them about TB.
“Ongoing support in the community makes a huge difference. When you have an illness, a lot of times being in the health-care system it can feel like everything is out of your hands, and one can just feel like they are going with the motions and may not feel comfortable sharing because everything is going so fast,” she said. “So, just having a nurse go to their home, and really asking the client, ‘how can we help?’
“I find a lot of satisfaction just being there for them and supporting them and watching the improvement over time as well. I’ve met some amazing people.”
Susan Spina and Doris Ho are registered nurses who, along with their colleague Gian Fauni, are part of the NLOT team at Sunnybrook Health Sciences Centre. They visit five long-term care homes in Toronto. Spina and Ho both have backgrounds working in hospitals, 30 and 15 years respectively, and say community outreach work is a completely different mindset.
“In the hospital, especially in the emergency department, you want to find the problem, you want to treat it, and they either get admitted or you fix the problem,” said Ho. “In a long-term home setting a lot of different things come into play. For example, what their goals of care are. So, something as simple as an infection, it depends on what the family and patients want.”
Providing care in the home is also preferred when it comes to long-term care residents who have dementia. Having them receive care in an environment they are familiar with, and with their care workers there and where they can keep their routine, is good, Ho said.
“They are in their own home. When we are giving an IV antibiotic, they are watching TV,” she said.
“There are a lot of benefits for them to stay home,” said Spina. “They are in a familiar environment, their ability to get fed is big. When you are looking at causing delirium, emergency (rooms) and hospitalizations are huge risks for causing increased delirium because they are not getting drinks, they are not getting drinks provided, they are not getting the food provided because there is not enough staffing availability.”
Spina said she loves being able to do this outreach work. She said getting to go into the long-term care homes and make a difference for the residents and their families, as well as support the staff and nurses, is a pretty huge feeling. “There is a lot of gratification involved in going in there and giving someone their IV medication and watching them get better.”
Althea Moncrieffe, a registered nurse with Scarborough Health Network who is part of its Nurse-Led Outreach Team, said returning to the same long-term care homes each week means they get to know the residents, which also makes a difference in their care.
Scarborough Health NetworkAlthea Moncrieffe is a registered nurse with Scarborough Health Network who works on the same NLOT team as Ong. She said returning to the same long-term care homes each week doing outreach means they get to know the residents, which also makes a difference in their care.
“They are comfortable with us,” she said. “It helps. For example, things that the patient would have gone to emergency for, for example, a G-tube (gastric tube) insertion. Now, they call us if they need it so the patient doesn’t need to go to the emerge and stay on a stretcher overnight.
“I get to advocate for the patients a lot in the homes and I really, really like that,” Moncrieffe said.
Ong said she sees the importance of outreach work every day. “Especialy when we are able to prevent an unnecessary emergency room visit,” she said. “Instead, we allow them to be in their home, where they are more comfortable and we still provide that hospital-level expertise.”
