Rapid Response Nurses perform a vital function in our network of health care services. By facilitating smooth transitions from hospital to home, they act as a bridge to support patients with complex and high care needs.
We help connect you with community or home-based primary care and ensure that appropriate follow-up appointments are scheduled.
This program is intended for short-term intensive assistance and is not intended to replace the services provided by service providers.
We will work collaboratively with your existing network of health care professionals, hospital staff, primary care providers and community agencies to help you avoid unnecessary hospital re-admissions following discharge.
Rapid Response Nurses will help you:
- understand your illness and symptoms,
- understand your hospital discharge plan,
- understand how to take prescribed medications,
- arrange for follow-up medical appointments or tests,
- connect with your primary care providers, and
- receive appropriate home supports as quickly as possible so you have everything you need to stay at home safely.
Central West Rapid Response Nursing Program Criteria:
Medically Complex frail adults and seniors who are diagnosed with Congestive Heart Failure (CHF) and/or Chronic Obstructive Pulmonary Disease (COPD) with one or more of the following:
- High risk for possible readmission to hospital or Emergency Department
- At risk for poly-pharmacy (e.g. more than three medications for multiple chronic diseases)
- Frequent hospitalizations: more than two admissions in a three-month period
- Frequent Emergency Department visits: more than four in the past year
- Assessed to have a fragile support network
Please note: The Rapid Response Nurse does not replace a regular nursing referral for treatment such as IV and wound care and is not acting in the role of a Care Coordinator.