Hospital nursing team serves seniors in long-term care

After receiving a lung cancer diagnosis at 80, Jane Esodo and her family decided it would be best for her to move to a long-term care home to receive the support she needed. But when Jane’s daughter, Rossana, helped her move there in early February, she didn’t realize how much more her mom’s life would change. Within just days of settling her mom into the residence, the COVID-19 pandemic hit and stringent visitor restrictions were put in place to protect the health and safety of residents.

“I went from seeing my mom almost every day, to only seeing her on the drive to her medical appointments,” said Rossana. She recalls the first trip she made with her mom to Osler’s Brampton Civic Hospital for cancer treatment. Due to the necessary visitor restrictions, Rossana couldn’t accompany her mom to the appointment. “I wasn’t sure what the protocol would be and was very nervous for my mom. After all, between my sisters and I, one of us used to go with her to the hospital and wait with her while she received treatment.”

What happened during that first hospital visit was a seamlessly orchestrated plan by Osler’s Nurse Practitioner Lead Outreach Team (NLOT) to ensure Jane’s visit went as smoothly as possible. Jane and Rossana were greeted by Joan Reid, a Geriatric Emergency Medicine (GEM) nurse who escorted Jane to the appointment and provided support while she was in the hospital. GEM nurses are geriatric experts who ensure seniors who are at risk of adverse events get extra care. Joan checked-in regularly to ensure Jane was doing well, offered her coffee and snacks, and made her visit more comfortable.

“After meeting Joan and seeing how knowledgeable she is and how she interacted with my mom, I was quickly at ease and was pleased that she could be there for my mom during her visit,” said Rossana.

Behind-the-scenes organizing this visit and many others is Sheelagh Willett, a NLOT nurse practitioner. She worked with Jane’s long-term care home to coordinate her care while she was at the hospital.

The NLOT services aren’t new to Osler, but have grown in recent months to provide care to more seniors living in long-term care homes. These homes have been hit especially hard during the COVID-19 pandemic. The small but mighty team of five, has grown to include seven Nurse Practitioners who receive support from other seniors programs and GEM nurses who assist with delivering care.

“We have increased our supports during the pandemic to include a comprehensive virtual strategy, which includes planning for what residents may need and connecting them to our hospital services and programs,” said Sheelagh. “We provide access to virtual care through a variety of clinics and programs including ambulatory care, palliative care, geriatrics, mental health, internal medicine, the Emergency Department, and diagnostics.”

In addition to this, not only has the NLOT team gone in to help long-term care homes in crisis, they have helped organize technology donations through technology donations, and supported transitions back home for long-term care residents who are inpatients at Osler’s hospitals.

Through their approach to care and care coordination, NLOT plays an important role in helping long-term care residents avoid unnecessary transfers to hospital and reducing urgent visits. And for patients like Jane who must come to the hospital for care, their goal is to make the visit safe and comfortable.

“We’re looking to also minimize the senior’s risk of exposure and make their care as quick and as seamless as possible, all with the goal of protecting our seniors population,” said Joan Reid, GEM nurse.

Jane continues to value the support she receives during her hospital visits and says, “to me, this is a beautiful service. It was very organized care.”