Growing partnership connects care for vulnerable populations

A growing partnership between Osler and Peel Region’s Community Paramedicine Program (CP Program) is bringing peace of mind to seniors living with chronic diseases and complex health conditions while also having a positive impact on the broader health system.

“These vulnerable populations sometimes fall through the cracks once they return home following a discharge from hospital, leading to more 911 calls, repeat Emergency Department (ED) visits, and hospital readmissions,” said Dr. Neil Dattani, an Osler emergency physician and one of two clinical leads with shared medical oversight for the CP Program. “But thanks to a passionate team of hospital and paramedic leaders, we’re closing this gap as we work together to seamlessly integrate our services to benefit both our patients and our health system.”

Osler referrals to the CP Program ensure eligible discharged hospital patients can safely manage their health conditions at home, which in many cases, involve one to three visits to the home by an extensively trained, senior-friendly paramedic, depending on a patient’s care needs.

Peel paramedics deliver timely, in-home care

“Our paramedics customize a care plan - which may include non-emergency medical services - based on each patient’s needs, to ensure they’re stable and, when needed, help connect them with other health and community services that enable them to age safely at home as long as possible,” said Mike Nunez, Community Paramedic Superintendent, Peel Regional Paramedic Services.

“This partnership is about getting patients optimal care in the right place. It’s a great example of the work being done to coordinate care for elderly patients in our region,” said Dr. Neil Dattani, Osler Emergency Physician, Clinical Lead, Community Paramedicine Program.

Trained in chronic disease management and the care of older patients living at home, the paramedics can complete cognitive and geriatric health assessments, perform blood and urine tests, conduct bladder scans, perform intravenous and fluid therapy, and administer medications for chronic obstructive pulmonary disease (COPD) and diuretics for congestive heart failure (CHF). Medical oversight by physicians enables the paramedics to perform functions in the home over and above those services available through home and community care services.

Osler growing CP Program referrals across programs

Although the partnership initially launched with referrals from Osler’s Seniors Program and EDs in 2022, Osler has since grown its discharge pathways to include eligible inpatients and, more recently, eligible patients enrolled in its Remote Monitoring Program, further expanding its outreach to those in the community who can benefit most from the CP Program’s services.

Anne-Marie Graham, Director, Cardiovascular, Stroke and Chronic Disease, whose nurse-led Remote Monitoring Program monitors 140 patients living with COPD and CHF, was pleased to have the opportunity to partner with the CP Program.

“We remotely monitor patients’ vital signs and symptoms in our program for six months, and during that time, if a patient shows signs of becoming unstable, we usually have to send them to the ED or their family doctor for further assessment or medication changes,” said Anne-Marie. “Since January, however, we have been co-sharing some of our patients with the CP Program, meaning if a patient, for example, is having shortness of breath, a paramedic can visit the home, listen to their lungs and administer the necessary medication if needed, preventing unnecessary visits to the ED.”

“We’re all working together to help keep people safely in their homes as long as possible, while helping to reduce the burden on emergency services and hospitals,” said Mike Nunez, Community Paramedic Superintendent, Peel Regional Paramedic Services.

Francesca Fiumara, Director, Emergency Services, a long-time champion of the CP Program, is also pleased that the paramedics are now participating in ED multidisciplinary rounds at Brampton Civic Hospital once a week.

“Having the paramedics join our team has helped bolster relationships, increase knowledge about the referral criteria, and led to the identification of potential candidates for the program,” said Francesca.

Another enthusiastic Osler leader is Terri-Lynn Hansen, Director, Acute General Medicine, Critical Care, Respiratory Therapy and Transitions, whose team of transitional care coordinators taps into the CP Program for discharged inpatients who may require a check-in when they get home.

“Often patients with high needs are nervous about returning home following a hospital visit, so a visit from a senior-friendly paramedic in the CP Program following discharge provides that added reassurance they will be able to safely manage their condition at home,” said Terri-Lynn.

Eligible patients may be referred to the CP Program by emergency physicians, hospitalists, geriatric emergency management nurses, transitional care coordinators, and nurses in Osler’s Remote Monitoring Program, reflecting an integrated approach to the partnership across Osler programs.

Delivering the right care in the right place

“This partnership is about getting patients optimal care in the right place,” said Dr. Dattani who notes that paramedics will go beyond issues identified in referrals and take into account activities of daily living and social needs or supports when in the home. “It’s a great example of the work being done to coordinate care for elderly patients in our region, which aligns with the mandate of Ontario Health Teams.”

Mike Nunez agrees wholeheartedly.

“We’re all working together to help keep people safely in their homes as long as possible, while helping to reduce the burden on emergency services and hospitals. Not only are we improving outcomes for residents but also enhancing the efficiency of the health care system in Peel Region.”