“The different environment can be a trigger for delirium.”
At some point on the dementia journey, you will inevitably end up, panicky, at the emergency department.
The Alzheimer’s tide is rising, and with end-stage dementia, your loved one will inevitably experience a fall (and broken bone) or a urinary tract infection (from dehydration, leading to worsening dementia) and other troubles arising from the disease.
Hospitals are increasingly under stress to keep up with emergency care for growing populations and aging population. A number of hospitals are adopting the Home First philosophy. Yes, it’s an attempt to free up beds for acute care; but the philosophy is sound. Provide a network of care to help people get home and stay home.
Here is a spotlight on one health care centre, the Halifax Infirmary at the Queen Elizabeth II Health Sciences Centre, in Nova Scotia.
“Discharge planning begins the second you walk in.”
This is Jonathan Veinot talking, a 29-year-old man who speaks with the wisdom of ages. He is one of the Discharge Planning Nurses in the Emergency Dept. at the QEII Halifax Infirmary, a teaching hospital in Halifax, near The Common. He has a degree and a slew of credentials – and if you have a loved one with dementia, this is the guy you want to have your back.
There are likely many Veinots in hospital emergency rooms across Canada. QE11 has two full-time DPN positions (filled among four people); and Dartmouth emergency also has two.
Because of this cluster-storm of conditions – aging population, increasing incidence of dementia, family members who head to ER first – a number of hospitals are adopting the Home First Philosophy. To date, the list includes B.C., Saskatchewan, Ontario, New Brunswick, in addition to Nova Scotia.
It’s a patient-centered program meant to help seniors stay independent (which they want) and get them out of hospital. The reason: A medical institution carries many risks for the patient living with Alzheimer’s and the frail elderly. Veinot’s hospital has implemented the program too.
Right away, “the different environment can be a trigger for delirium,” says Veinot. The increased confusion patients experience sometimes leads to broken hips from attempting to crawl out of bed. “They try to elope. They want to go home,” he says. here are bed sores, medication errors, pneumonias or blood clots from decreased mobility.
Nevertheless, when health problems reach a critical point and caregivers naturally turn to a hospital. Veinot says that about 50 percent of those being admitted to his hospital are the frail elderly or someone suffering a health problem associated with dementia.
“We provide system consultation, not only navigation, for patients. Many times doctors or specialty services will approach us in the ER to ask for our assessment, such as delirium testing, to see If we can get patients home instead of becoming admitted,” Veinot says.
People do better at home, “especially in the geriatric population, getting treatment in their home, in their own environment. And with dementia and Alzheimer’s on top of that,” he adds.
Although the hospital’s policy is to get folks home before admission if they can, with appropriate support, the system is flexible enough to house those who do not have a “medical need.”
“An elderly man with dementia starts to wander at night and his elderly wife can not care for him anymore. And he has been on the LTC waitlist for two years already. He is not safe to go home.” Veinot reports to Adult Protection Services and the patients end up staying in the emergency department for up to seven days until the next nursing home bed becomes available.
Veinot’s job is akin to running a military campaign on many fronts. Here is a short list of what he does for patients and their caregivers:
At the emergency department
- Assess client frailty, functional ability, cognitive status and mitigate risks of clients living at home with the hospital’s information and community resources. “Can a dementia patient who comes in with increased confusion secondary to a UTI go home to continue to live alone, with home supports we arrange – such as personal care, meal prep, light housekeeping, nursing homecare visits – or do they need to be admitted?” he says.
If a patient has been admitted and then discharged
- Request, through Continuing Care NS (CCNS), Victoria Order of Nurses’ home-based services, including administration of antibiotics to clients who have been seen in the ER. Other services – dressings, medication administration for people with dementia, bowel monitoring, palliative support, pain management.
- Request assessment through CCNS for suitability of patients to be placed on the long term care waitlist, and request assessments by physical therapists and occupational therapists.
- Refer patients to specialized clinics such as the geriatric falls clinic, geriatric memory clinic, palliative care team, nutritional clinic, diabetic education clinic, etc.
Caregivers are understandably distressed about loved ones returning home after a hospital stay. Veinot goes out of his way to make the transition seamless.
“Often, the only thing preventing them from going home is a wheelchair or walker.” He will call Red Cross and get patients a mobility device, for about three months (although the Red Cross won’t come knocking demanding it back), at no cost. “They just ask for a small donation when you return it.” They also offer canes, raised toilet seats, commodes, etc.
He has a group of private companies, such as Northwood Homecare and Phillips Lifeline that he can call to cajole for electronic pill boxes, bed alarms and other tools – “toys and tricks” – that will help with safety and monitoring at home.
“Not only do we help seniors stay independent but we must make sure they are SAFE… Safety is a huge portion of our assessment.”
Continuing Care Nova Scotia services are coordinated across through: 1-800-225-7225 Call between 8:30 a.m. and 4:30 p.m., seven days a week. For more information, click here
HOW FAMILIES CAN HELP
Contact your family doctor first:
- GPs can sometimes offer solutions to help alleviate issues at home.
- Some GPs still do home visits.
- GPs can access home care. Example: Instead of coming to the ER when you have a leg infection because you might “need IV antibiotics,” go to your GP first. GPs have the ability to set up VON to deliver home IV antibiotics.
- GPs can also send a referral to homecare to request for services (personal care, meal prep, light housekeeping).
If you decide to go to ED:
- Bring a complete list of medications (or physical bottles – including vitamins and herbal supps) and a list of medical problems or diagnosis ever made by a doctor, including surgeries. If you are a VON client, bring the VON care plan binder.
- Request family meetings with the doctor/DPN/social worker to plan the transition from hospital to home easier. “We rely heavily on ‘collateral information’; for instance, How does the patient normally function at home when doing x, y and z?
The QEII Health Sciences Centre has 1,100 beds, including 175 beds dedicated to veterans; admits approximately 31,000 patients annually; sees 70,000 patients in its emergency medicine departments annually; and records approximately 375,000 ambulatory clinic visits annually.
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