Easing transition back home

November 2010 Vol 11 Issue 7

web 88852494Taking practice nursing into the home – to ease the rehab of elderly patients – was the aim of a Nurse Practitioner Facilitation project by Rotorua NP-in-the-making Vicky Gaunt. Fiona Cassie reports.

An elderly patient arriving home from hospital with new pills in hand can feel confused, tired and vulnerable.

As a practice nurse Vicky Gaunt found that Friday afternoons often brought phone calls from family members worrying whether their recently discharged elderly relative would manage over their first weekend at home.

With the hospital discharge letter often still on its way the practice was quite likely to not even know the patient was back home.
Gaunt, an NP-in-the making, decided this was one area where primary health could do better. So when innovation funding was made available in 2008 through the Nurse Practitioner Facilitation programme, she successfully applied.

The result was the Owhata Elder Care Transition Co-coordinator Project, which aimed to smooth the transition between hospital and home of elderly patients while helping to develop a primary health NP role for the Owhata Surgery.

Gaunt is a British trained nurse and midwife who first came to New Zealand as a young nurse on her OE before eventually emigrating in 1994. She worked in New Zealand as a midwife for five years before starting work at the Owhata Surgery, on the outskirts of Rotorua, as a practice nurse in 2000.
Having done some primary health agency work in the UK she was not new to primary health but did find some aspects of primary health down-under quite different. Particularly as she was used to district nurses, health visitors (equivalent of well child nurses) and community midwives being centrally based in a community practice and talking to each regularly about the patients they shared. “It took me a bit to get my head around that really.”

In 2004, with the help of a Clinical Training Agency grant, she dipped her toe into postgraduate study with a child and family assessment paper and last year completed her Master of Nursing degree with Honours through Massey University.

With prescribing NP status in her sights, she began the transition co-coordinator project to see if an NP role could help ease the process of returning home from hospital for elderly Owhata Surgery patients. With three days of the week dedicated to working on-site at the practice, a further half to full day working on her NP prescribing practicum, the co-coordinator project swallowed up the rest of her week. Juggling the project, postgraduate study, family and her normal workload was not always an easy task but she could see the potential rewards of such a service.

Communication was a key element, so in the lead-up to putting the project into action, Gaunt met with ward nurses and respiratory and diabetes specialists at Lakes DHB to share her plans and met with the board staff responsible for allocating community support services.

Most importantly she successfully requested to be regularly emailed the admissions and discharges of Owhata Surgery patients so she knew who could need her help when the 12 month role kicked off in December 2008.

Once alerted, she contacted all the surgery’s recently discharged patients aged over 65 within 24 to 48 hours. The majority of the 72 eligible patients were in their late 70s to early 80s. And, with the exception of “one chap”, the contacted patients were very keen to have their practice nurse get in touch and were open to a home visit. “It was very well received.”
On arrival, she found some patients and their spouses unsure how to take the new tablets, others had started warfarin, which needed careful monitoring or had started blood pressure pills and were a little unsteady on their feet.

Others who may have put on a brave face at the surgery were found to be struggling to manage household tasks following their time in hospital. “You do find out a lot more when you visit them at home against seeing them at the surgery.” Other issues also emerged during home visits, continence for one, and she was able to arrange a referral to a continence nurse or for physiotherapy or occupational therapy assessment.

Gaunt made 61 home visits during the project, with other patients seen at the surgery or hospital. The key barrier, she says, was finding the time.
While the majority lived within 5km of the surgery, some lived at outlying lakes up to 20km away. Once there, a home visit could take an hour and a half but the time invested did reap rewards, says Gaunt. Particularly having the extra time to sit down and talk a patient through their new medication or provide reassurance. Also to grab the chance to go through their old medication and remove outdated or no-longer-needed pills.

During home visits she had a laptop with remote access back to the patient’s files at the surgery, so she could see what their medications had been prior to admission, and could confer with their GP to ensure their medication records were updated. Also, while patients are encouraged on discharge to have a follow-up appointment with their GP, many did not and the visit provided that link back to the surgery.

The majority of the project patients were already enrolled in Care Plus and nine more were subsequently enrolled, reflecting their level of chronic disease. Gaunt sees a role for home visiting as part of Care Plus, so also used the project to visit some non-hospitalised elderly Care Plus patients and found those visits valuable too.
One of the aims of the project was to reduce hospital re-admissions, but 45 per cent of the discharged project patients were readmitted which, she says, was mostly a reflection of their complex medical issues and age. A number were at the stage of going backwards and forwards to hospital as the need to move into residential care became more inevitable.
Funding for the project ended in late 2009 but Gaunt continues to receive the discharge lists and follows up patients when she can. With the feedback positive from patients, families, GPs and fellow nurses she would like to see the project become part of a future NP role at the surgery.