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Erie St. Clair CCAC Rapid Response Nurses

​The Erie St. Clair Community Care Access Centre's (CCAC) Rapid Responses Nurses program has helped Nora to transition smoothly from hospital back to her home. Following her discharge from hospital, Nora was visited by Mark Seney, a Rapid Response Nurse (RRN) at the Erie St. Clair CCAC's Chatham site. Mark helped Nora to manage her congestive heart failure (CHF) and diabetes during the crucial first 30 days following her discharge.

The Erie St. Clair CCAC's RRN program is part of a provincial initiative that aims to prevent the readmission of frail and elderly patients being discharged from hospital and, more recently, those referred through emergency department (ED) visits. The Erie St. Clair CCAC's program focuses on patients with one or a combination of three chronic conditions: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and diabetes.

Rapid Response Nurses visit referred patients within 24 hours of their hospital discharge, continuing to regularly visit them for 30 days. The nurses take on a role of intensive care coordination. They perform comprehensive assessments, medication reviews and health education as a means of educating patients on their conditions, symptoms and medications. Through this work, RRNs work to prevent hospital readmissions and emergency department (ED) visits.

"Mark has been helping me in many ways – such as checking my blood pressure," said Nora during one of her visits with"" RRN, Mark Seney. "I greatly appreciate all the care I receive from Mark. I am progressing nicely."

"As a Rapid Response Nurse, I enjoy seeing patients immediately after their discharge from hospital. This is the best time to provide education about their conditions in terms they can understand and it is very rewarding," said Mark Seney. "For example, many patients have no idea why they are taking certain medications. Providing clear, concise information helps patients to understand what their medication is for. Ensuring they take the correct medications, by working with their pharmacy and primary care providers, provides the best outcomes and most satisfaction to patients, their families and the Rapid Response Nurses."

Working with community health partners is a large part of the RRN program. Not only do the Rapid Response Nurses work closely with community pharmacists, they also work with primary care providers through information sharing. Rapid Response Nurses send their comprehensive assessments to their patient's primary care provider and help to set up an appointment for the patient with his or her physician or nurse practitioner within seven days of discharge. The RRNs also request primary care provider assistance for medication reconciliation when needed. In this way, Rapid Response Nurses liaise with family health teams, physicians and nurse practitioners. They are also currently working with hospital partners to educate on the program and increase referrals.

The program has seen great success so far and referrals are continuously increasing. In 2013, there were 263 referrals to the Erie St. Clair CCAC's RRN program. As of Wednesday, April 9th, 2014, the program had already seen 284 referrals – exceeding the previous year's numbers. There are currently eight RRNs overseeing these referrals – four for Windsor-Essex, two for Chatham-Kent and two for Sarnia-Lambton.

As the program continues to grow, the goal is to reduce readmissions to hospital among these patient populations. "The RRN program is invaluable to our community," said Maureen Eyres, Patient Services Manager, Professional Practice Leader. "By providing immediate care to patients after discharge from hospital and emergency department, the RRN is able to support the safe transition from acute care to home."