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Rapid Response Nursing – a bridge from hospital to home

"I would have been dead without the North East CCAC."

To call Cathy McKay of Powassan grateful would be an understatement. Earlier this year, Cathy, who has suffered from Chronic Obstructive Pulmonary Disorder (COPD) for the past seven years, couldn't catch her breath even with her medication. X-rays taken at the hospital showed vastly diminished lung capacity, and at the end of her hospital stay, it was clear she would require ongoing support.

"It's hard, you know? With COPD, things change day-to-day. You're never really great, and even though some days are better than others, you never know how you're going to feel when you wake up so you can't really plan anything," says Cathy.

Cathy swears that all changed when she met CCAC Rapid Response nurse, Jennifer Hunt after her discharge.

For patients dealing with a chronic disease like heart failure, COPD, diabetes or dementia, or those with complex needs who have experienced multiple hospital admissions or trips to the Emergency Department, Rapid Response nurses help ensure care is in place and patients are coping well post-discharge from hospital. Typically, the first visit with a Rapid Response nurse will take place within 24 to 48 hours of the patient's return home (although consideration is given to patient preference, as some prefer to get settled in before they schedule a visit with the nurse). Last year, 752 patients received care from Rapid Response nurses in northeastern Ontario.

The Rapid Response nurse's first priority is to assess how the patient is doing physically and communicate any health concerns to the patient's primary care provider. They review hospital discharge care plans with the patient and ensure that all follow-up appointments are booked, including scheduled tests and blood work. Another important task is medication reconciliation.

Jennifer-Hunt.jpgAccording to Cathy, Jennifer (pictured left) played a key role in keeping her out of hospital. "Jennifer was wonderful. We realized I was allergic to one of the medications I had been prescribed. So she took care of that, got rid of some expired medication I had and explained everything to me. And whatever she thought I was going to need, she made sure I had it or else she talked to the doctor to make sure I was going to get it. She really advocated for me. Anybody who gets CCAC services is lucky. You couldn't get a better organization, from the nurses to the dietician to the lady who answers the phone! They all really helped calm me down and made me feel better about the way the whole health care system works together."

Jennifer also helped ensure that Cathy would be seeing a lung specialist, and referred her to the CCAC's Telehomecare (THC) program for ongoing care.

Now, through education provided by THC, Cathy says she is eating right, and taking better care of herself and her condition. Even though she has nothing but praise for Jennifer, Cathy says she hopes to avoid any need for visits from a Rapid Response nurse in the future. "I hope Jennifer won't take this the wrong way, but hopefully I won't have to see her again!" Cathy laughs.