There’s an “epidemic” of disjointed communication through the health care system, according to a Thompson Rivers University nursing instructor.
But there’s hope in a pilot project that’s been so successful the TRU School of Nursing — in partnership with Interior Health — has adopted it as part of its regular curriculum.
In 2011, the Ponderosa Pathways program began exposing second and fourth year TRU nursing students to the continuum of health care that injured or sick seniors go through from hospital to home.
“Our population is indeed changing, it’s aging, and this is something that we need to address,” said Michelle Funk, TRU nursing instructor.
The two-year research project at Ponderosa Lodge involved approximately 36 nursing students, 30 to 50 practitioners and 90 to 120 clients and their families.
The program was designed to prepare future nurses for the emerging health care system as well as reduce patients’ returns to hospital.
“It’s a carousel for some of our elderly out there because they lack the social support in the home,” said Funk.
Students prepared seniors to live at home safely without a reoccurrence back in hospital. This was accomplished by educating patients and their families on home care needs and community resources both before discharge and during follow-up home assessments.
The program was a comfort to patients, as an anonymous woman explained in a video on the project.
“They taught me to be on my own, independently. And I had people there if I needed to call on them.”
It also led students to realize that not all patients at Ponderosa are at the point of needing long-term care.
“These were very independent seniors and spry,” said Funk. “One of the patients said she had so much work to do when she got home. The student thought, ‘Well, you’re 89, you don’t go to work, you’re retired.’ What she meant by work was going to physio and staying active.
“It just totally changed the students’ mindset about seniors living at home.”
Mindsets are also changing among health administrators as increasing emphasis is placed on getting patients home as quickly as possible.
The transition towards that method has been very disjointed so far for Interior Health and many other health authorities, said Funk.
“We need to work closer with home health to make those links with them regarding which patients are being seen, which patients aren’t being seen,” she said.
The nursing students’ efforts have accomplished great results, however.
In one instance, a home visit with an elderly man who had returned to hospital twice for a broken hip revealed a simple solution.
It turned out that home care staff had placed his bath chair at the back of the tub. The patient didn’t realize it could be moved so he’d fall when attempting to adjust the taps.
“So he’d been to the hospital twice,” said Funk. “That’s extremely taxing to the hospital resources.”
Student Amanda Shibley said she’s now better prepared to connect patients and families with the help that’s available in the community.
“I feel like I know so much about the resources out there now. I had no idea of any of this for patients — there’s just endless resources in this town. I wouldn’t have thought of how they will cope after they leave RIH,” she said.
Jeremiah Reid went from being a second year student when the pilot project began to a leader training his peers this year.
The experience has been a revelation to him.
“I realize that it can be very scary for patients after a life changing surgery or health change to be sent home with no guidance,” he said.
“As a nurse, I will always try to think this way for the remainder of my career.”