Why do so many nursing home residents end up in emergency departments?

This January, Sylvia got a call from a nurse in her mother’s long-term care centre. Her mother, Angela, woke up “extremely agitated and crying in pain,” so the nurses sent her to the emergency department.

Sylvia was worried about how her 92-year-old mom, who has dementia, would react to the trip – the lights, the new faces and the loud noises.

Angela was in the emergency department from 10 a.m. until two the following morning. “They tried to eliminate this, they checked that, and so on,” recalls Sylvia.

“She kept asking where she was and what was happening,” says Sylvia. “She was getting more and more agitated.”

The final test – an X-ray of the spine – revealed that Angela had compression fractures, meaning she must have had a fall in the night. The doctors sent her home and told Sylvia to follow up with her mother’s family physician.

Sylvia thinks that the hospital visit was justified – even if a doctor had been available that morning at the nursing home, they wouldn’t have known what was wrong without the X-ray. But she thinks if there was communication between Angela’s regular primary care provider and the emergency department doctors, many of the tests could have been avoided.

And she’s worried about another emergency department visit, since nurses at her mother’s home often send patients there if a family doctor isn’t available. “The nurses are nervous, they’re overworked, and they’re concerned about their own liability, which is understandable,” says Sylvia.

In most provinces, access to primary care for nursing home residents is extremely variable. Some homes have a primary care provider on site five days a week. In many other homes, doctors do drop-in visits once or more a week.

Nursing staff can usually call a patient’s provider, but sometimes they avoid calling to not overburden the doctor. In other cases, providers are busy seeing other patients so even when they’re called, they suggest the emergency department.

“The arrangements are all over the map,” says Evelyn Williams, president of Ontario Long Term Care Physicians. “It would probably be preferable that in-person assessments with an attending physician or nurse practitioner are available on a daily basis. However, we have got a long way to go to make that happen.”

David O’Brien, senior vice president of Primary and Community Care at Alberta Health Services, agrees that the models for care are “a bit eclectic,” with some patients being cared for by one provider and others by a team of providers, leading to different access levels. But he says the variability is justified – having nurse practitioners available five days a week may work for an urban area, but may be too expensive for a small, rural LTC home. “I’m not sure that one model actually works,” he says.

O’Brien adds that AHS hasn’t yet evaluated the outcomes of the different models of primary care for LTC centres. “We’d like to get to that point, but we’re not there right now,” he says.

Still, Samir Sinha, a geriatrician at Mount Sinai Hospital in Toronto, thinks that more standards for primary care access are necessary. “There needs to be an obligation that…homes be able to get access to a primary care provider on a 24 hour basis,” he says. He also thinks there should be more standards on the type of care residents receive. When he worked in Maryland, U.S., for example, there were state minimum requirements on how often medications need to be reviewed, he points out.

Emergency department visits can worsen health issues

Howard Ovens, chief of the department of emergency medicine at Mount Sinai Hospital, has seen many cases where nursing home residents arrive at emergency departments because the staff nurse didn’t have access to doctors or nurse practitioners who can provide an assessment. He recognizes, however, that he only sees the select group that show up in emergency – he doesn’t see the patients who receive timely care and therefore don’t need to be sent to his hospital.

“They’re taken out of their home, a familiar setting, to a strange environment where they don’t know any of the people,” explains Ovens. “They may not understand where they are or why they’re there.”

Meanwhile, emergency department doctors may perform more tests and treatments than are necessary because they don’t know the patient. Elderly people may want more comfort-oriented care at the end of life rather than have all their health problems diagnosed and responded to, for instance. And, yet, says Ovens, those working in the emergency department sometimes don’t see such directives on a patient’s health record. More often, the directives are available but “inadequate to really understand what their goals of care are.”

In many cases, says Ovens, when patients can’t speak for themselves (in Ontario, 42% of nursing home residents have been diagnosed with dementia), they will  already have had procedures done, like an IV put in, before the family has even arrived to discuss the approach. “The emergency department is geared for action. Our default will be to intervene,” says Ovens.

Cindy Forbes, who is pushing for improved access to well-coordinated primary care for seniors in her role as president of the Canadian Medical Association, points out another major problem associated with emergency department transfers. “Hospitalizing elderly people often puts them in the situation where they might be exposed to infections,” she says. And if an infection or other major issue causes a patient to be kept in the hospital for more than a month, in some regions they risk losing their LTC bed.

But Williams points out that even when a primary care provider is available to assess a patient in the nursing home, they may still have to send them to the hospital to access an X-ray or lab work. In many nursing homes, Williams says laboratory staff only pick up samples once a week. There is also the issue of what kind of care is available once the family doctor leaves. “A patient may need to have a nurse who is able to monitor them throughout the night, who may not be available.”

In some small or under-resourced LTC homes, emergency departments may be the most efficient and timely way to provide care, compared to having resources available in homes with small resident numbers, Williams argues. “Perhaps the answer is not to provide more expansive services where it’s difficult, but to provide services better and more efficiently to elderly people in the emergency department.”

Of course, there are times when the emergency department will be the best place for an elderly patient in a health crisis. “If there’s any doubt, the emerg is a very effective place to get a rapid, broad examination done,” says Ovens.

Programs arising to better serve nursing home residents

Across Canada, more and more programs are being funded to bring primary care to patients in long-term care (LTC) facilities. In Nova Scotia, a program called Care By Design “has been heralded as one of the leading models,” says Forbes.

Barry Clarke, a family physician, implemented the program in 2009, after research had shown that 75% of those admitted to a LTC facility were sent to the emergency department at least once a year. (In Netherlands, by comparison, only 5% of nursing home residents visited emergency departments annually.)

A big part of the problem, says Clarke, was that family doctors were spread thin, sometimes seeing several patients in numerous facilities. “It was care by default. Many people couldn’t get access to good primary care when they needed it, so they defaulted to a hospital admission,” explains Clarke.

With the roll out of Care by Design, a family doctor is responsible for patients on one floor of a nursing home, and supported by a team, often including a nurse, pharmacist, and physiotherapist. Standards of Care were also established. Doctors take on call shifts where they are responsible for any emergencies in a larger patient population. “Doctors on call have to be available by phone within 30 minutes,” says Clarke.

The doctor or nurse practitioner can also call on Extended Care Paramedics, who are able to provide some of the tests and treatments that patients were previously sent to the hospital for. “They can do cardiograms, they can do IVs for antibiotics and they can do stitches,” explains Clarke. A recent study found that the extended care paramedics – who are available from 8 a.m. to 8 p.m. – were able to treat 73% of patients on site.

Clarke reports the program has brought emergency transfers down significantly, by 40% to 65%, though his analysis has yet to be published.

Health systems are also working to ensure better communication of health care wishes. Over the last few years, the province of Alberta has implemented a program that aims to bring much more detail and standardization into these conversations. Patients keep a standardized document that comprehensively outlines where they want to be cared for and how much intervention they want, in a standardized green folder. Paramedics have been trained to ask for the folder, says Eric Wasylenko, the program’s medical advisor. He explains program was put in place in part because fully informed people who indicated a wish to remain at home for care, and avoid hospitalization, were still being sent to the hospital.

In Ontario, the government is responding to the access issue by funding up to 30 new nurse practitioners to provide full time care in LTC facilities this fall. The government will add up to 75 nurse practitioners by the end of 2017, according to government spokesperson David Jensen.

Michelle Acorn, the lead nurse practitioner at a hospital clinic for geriatric patients at Lakeridge Health Hospital in Whitby, says that the number is far from what the Nurse Practitioner Association of Ontario and Registered Nurses Association of Ontario have been calling for: one nurse practitioner per home (there are more than 600 LTC facilities in Ontario).

The benefit of having providers on site, says Acorn, is that they are more likely to focus on prevention. For instance, falls may occur because patients may be on too many medications – so providers who have more time with staff can work to implement new strategies and protocols to decrease medications – as Care By Design has done. “A lot of things can be averted if you are proactive versus reactive,” says Acorn.

Physician assistants can also play a role in preventative care. Michael Peirone, a physician assistant in Barrie, sees all of his patients, in several nursing homes, two times a month, in consultation with Dr. Kelley Wright. Their philosophy is that many emergencies can be warded off if early symptoms are noticed. For instance, sudden weight gain could be an early sign of heart failure, but if it’s addressed quickly, an ambulance trip can be avoided.

“I think it’s more common for physicians to pick a day or half a day a week. They run in and put out any fires that have accumulated during the week,” he says. “It’s very crisis-based.”

The names of the patient and her mother have been changed.

The comments section is closed.

  • Herb Trasker says:

    In the late 1970’s world renowned oceanographer Jacques-Yves Cousteau undertook a groundbreaking study of the mating habits of the Ocean Sunfish (Mola mola). Cousteau found that that mating ritual involved the fish dilating its anus to attract a mate. When Cousteau accidently inserted his finger into the fish’s anus, the fish rocked back and forth in orgasmic pleasure. As Cousteau summarized in French “ Quand mon doigt est entré dans l’anus du poisson, j’ai senti un avec le poisson et je suis sûr que le poisson a senti un avec moi ” – When my finger entered the anus of the fish I felt one with the fish and I’m sure the fish felt one with me. The Ocean Sunfish is the only known fish to display this mating behavior. In his later years Cousteau would often shove his finger up his own anus and fondly remember his encounter with the Ocean Sunfish

  • Cherese, Jefferson says:

    My mother is 83years of age she is none verbal she was discharge from the hospital after being there for over 57days she was then taken to another hospital by ambulance Transportation to the emergency room were she was diagnosed with malnutrition and sepsis and a bed sore she was given a antibiotic by iv and she was drop off at a nursing home with out the family consent. The nursing home excepted the patient with out admission forms and they did not except her insurance they did not contact her family to inform them that she was at there nursing home she was place in a room with no information on I called to conferm if she was there I was told yes But you can’t see her due to the covic19 pandemic.but you may fill out the admission packet: I personally think my mom’s Rights were violated I was not given any information from the emergency room Dr and I’m unsure of what her diagnosis are if she is distress at this time .

  • Trish Rawsthorne says:

    Excellent article. my question is what is the Netherlands and other Scandinavian countries doing so well that Canada is not? Could it be that the model of care is based on the social system versus the medical model where aging is designated ass a disease and treated as such?
    Something is wrong here and I believe that the standards are related to tasks and not to the “care” of people as in the social model where everything that touches or impacts the person is vetted and considered before implementation.
    I believe that we can do a lot better for those who need care if we abandon the medical model (they don’t follow this for child care) and adopt and learn from the social model.

  • Denyse Lynch says:


    • Clare Shields says:

      Until the legislators have loved ones in seniors’ care and experience the horrors, nothing will get done!

  • Laura Cory says:

    My mother has been in 3 nursing homes in Windsor ON during the last 3 1/2 years: Berkshire, Regency Park , and currently Huron Lodge. I am not happy about the medical treatment and care given to residents. She has dementia, is diabetic, has recurring UTIs and now resistant to antibiotics, and she acquired serious pressure sores on her feet while she was at Windsor Regional Hospital on Ouellette Ave. The medical training is substandard. If I did not make my own observations, many problems would have been overlooked until it was too late to do anything about them. I know that these problems can be avoided with more staff, better training, and respectful consultation with naturopathic doctors.

    My mother now has acquired more pressure sores on her feet, which I have reported to nurses at Huron Lodge. With proper care, this should not have happened. She and I are both miserable. This is no way to live out whatever time we have left on this earth.

    I am a bookkeeper. I have tried to find a detailed report on the internet regarding the latest financial statements on the healthcare division of the Province of Ontario. It should be part of public information, but I cannot find this report.

    Long-term care in Ontario needs a serious overhaul to be more respectful of the elderly. I believe that the current Government of Ontario is trying to subtly implement euthanasia.

  • Judith A. Wahl, Advocacy Centre for the Elderly says:

    In respect to the comments about “directives” in this article and the Alberta Green sleeve, assuming this article is about the situation in Ontario, these comments reflect a misunderstanding of the law about health care decision making and the requirements to get an informed consent . There is no such thing as a “directive” in Ontario that reflects decisions about health care . Health care providers are required to get an INFORMED consent prior to treatment , subject to the emergency exception . Patients when capable can express “wishes” about future care but these are speculative , without context and are not messages to health providers but are messages to the patients future Substitute Decision Maker (SDM). The problem is that in long term care settings, informed consent to treatments or a plan of treatment
    (which may be based and proposed and consented to after a goals of care discussion) are not necessarily being obtained. Some LTC Homes still use the inadequate levels of care forms that are meaningless and often in fact NOT DISCUSSED with the actual capable patient but completed by the residents family member s. Also the person assisting the senior or their family to complete such inadequate forms may not be able to discuss the patients state of health with them or the possible treatment options so nothing is being “informed” . There are variants of these documents out there — an the Alberta Green sleeve is just another variant that would not be legally correct in Ontario unless both amended to reflect Ontario law about health care decision making as the law is different here AND is only as good as the discussions with patients or the proper SDM for the incapable patient . Its very hard for the health practitioner next in chain that receives such documents to trust that the document and decisions reflected there in had been properly discussed with the patient or the correct SDM and properly recorded . Its time that health practitioners at all health facilities got back to basics of getting informed consent to treatment or a plan of treatment that could then be relied on by the next health facility . Its time for health providers to STOP looking for these “directives” which in many cases are meaningless and in fact do not reflect what the patient would want or not want as no one has had the discussions with the patient that lead to a truly informed consent on which everyone can rely . And it should be also understood that even if a patient did express some generalized wishes about future care to guide their future SDM , its up to the SDM to decide whether the wishes are still relevant ( not changed orally , applicable to the actual decision to be made, could be different if the patient had known how their condition would actually change) . That is why the Health Care Consent Act provides opportunity for SDMs to apply and interpret such wishes and to in fact deviate from those wishes if they believe that the patient would have made a different “wish” about future care if they had known how their health would change, Those interested in learning more about Health Care Consent and Advance Care Planning in Ontario might be interested in reading this paper attached to this link . This paper was a commissioned paper to the Capacity and Guardianship project of the Law Commission of Ontario which is reviewing the Substitute Decision Act and the Health Care Consent Act . The paper is an explanation of the Ontario law, a comparison of this law to that in other jurisdictions , as well as an examination of how it has been operationalized and why it is not operationalized correctly .

    • Trish Rawsthorne says:

      I support the informed consent process applying to the actual time of the event rather than asking residents to decide what they would like done in the future where their condition may have changed.
      My suggestion is to have a Health Care Proxy who is not necessarily the Power of Attorney but who is acting in the “best informed interests” of the person they represent. This is a legal document, and the elected HCP ought to be given the respect that they deserve because they represent the resident when they cannot make the decision.
      The Substitute Decision Maker or HCP ought to be chosen very carefully as a wrong decision can prove deadly for some. There are I believe certain characteristics that the SDM/HCP need to have – stamina being one, the ability to stand up for the rights of the person they represent and to be ethical and distance themselves at times from those claiming the moral high road.
      It is a difficult and at times fracturing position to be placed so it is not a position for the faint of heart.

  • Amie Chant, Canadian Institute for Health Information says:

    Very interesting article. The Canadian Institute for Health Information recently published a report on potentially avoidable emergency department (ED) visits. Some of the findings include:

    • In 2013–2014, 1 in 3 seniors living in long-term care visited the ED, similar to numbers for
    community-dwelling seniors
    • And 1 in 3 of their ED visits was potentially avoidable:
    – 24% of visits were for potentially preventable conditions. Urinary tract infections and pneumonia accounted for more than half (56%) of these.
    – 10% of visits were for non-urgent reasons not requiring inpatient admission. Falls accounted for 25% of this group.

    If you’re interested in wanting to know more the full report — Sources of Potentially Avoidable Emergency Department Visits — can be found here:

    • Trish Rawsthorne says:

      I do, and have, read all of the CIHI reports. I remember reading these or similar statistics and what I took away from these is that all of the above could have been prevented if the standards of care had mentioned anything related to the actual “care” of residents in these facilities. As well the need for adequate and appropriately trained staff to prevent these problems is of concern all across Canada and when speaking to residents in the facilities.
      If you leave residents in “diapers” up to 14-16 hours a day without changing them despite some curiously impossible rules of checking each resident every two hours, these residents would not be in the state they are in and needing to be treated for UTIs etc.
      If you keep elderly residents immobilized for the majority of their waking hours, then their respiratory systems are going to fail especially when seasonal flus appear and staff flit up and down to all the floors helping out if and when they can because staff were not replaced when regular shift staff become ill or go on vacation. You need recreational people and occupational therapists as well as physiotherapists on staff and tending to the needs of the residents>
      If you use chemical and physical restraints (approved by the powers that be) as a cheap and easy fix for the inadequacies of staffing, then you will need to send residents out for proper care.
      If you don’t have sufficient staff to feed or help feed residents, then they will not thrive and they will become sick and need to be admitted.
      If you insist on using inappropriate antipsychotics on the elderly especially when there is a Black Box warning against the use in the elderly with dementia, as well as a cocktail of other equally harmful drugs for depression or insomnia that actually carry a warning that these may cause cognitive confusion, falls and have a really long half-life, and yes residents will end up in the ER or worse in the morgue. CIHI has reported that despite not having all provincial data that at least 1 out of 3 residents in facilities in Canada are on inappropriate drugs. It is not good enough to say we are reducing the use of drugs and what a sad state of affairs to even have to admit this. The evidence is in, these drugs do not alter behaviours, but do scramble an already frail mind. Funny in a way that 1 in 3 admissions could be avoided, let’s try to actually do something to change this.

  • Laurie Poole, VP, Telemedicine Solutions, OTN says:

    Finding innovative ways to care for our fast-growing population of elderly persons with chronic conditions is a priority for the healthcare system, both from a humanitarian perspective and from a system sustainability perspective.

    At the Ontario Telemedicine Network (OTN), we believe that remote patient monitoring is one solution to the right care in the right place at the right time. Through OTN, for example, many long-term care homes have videoconferencing capacity to allow for remote consultations. Another good example is Telehomecare.

    Recently, we’ve taken Telehomecare – which provides remote vital sign monitoring and health coaching in their own homes to patients with COPD and Congestive Heart Failure — to patients in group and retirement homes. We plan to grow this service because Telehomecare is proven to reduce hospital admissions and emergency room visits by more than 50 per cent.

    As a complement to the care offered by Primary Care providers, technology-assisted solutions like Telehomecare can make all the difference to system costs but, more importantly, patient safety and satisfaction.

    • anonymous says:

      Avoidng ER visits is not an answer. I have seen many times that ER visits followed by proper care improved patient care a lot. Sometimes family physicians try to provide care that is beyond their expertise. Things like VS monitoring and health teaching are not enough for complicated COPD and CHF patients. Nursing home staff levels do not allow keeping those unstable patients, and it is not safe for those patients. UTI and pneumonia are not always avoidable. It can be a major liability issue if staff decide to keep patients instead of sending them to ER.

  • Dr Ralph Jones says:

    when I find surprising is the statement that in Ontario care Homes as “many “as 42% of the residents have dementia. In British Columbia this is 95%. In fact one does not get into a residential care home until all community options failed and frequently there is caregiver burnout..
    Here in British Columbia via the divisions of family practice we have a residential care physician program.It was initially 6 prototypes and is now rolled out across the Province. This program as robust evaluation and is designed to improve the medical care in the care homes and also at times of transition.
    I would agree that availability physicians or N practitioners is a major factor. However a large part of the problem is culture, cultured both within the care home and the culture amongst the family. Some of whom insist on transfer to the emergency department. our residents universally come back worse from the hospital than they left. Usually on a cocktail of unfriendly poisons

    • Morgan Kelly says:

      If doctors actually visited their patients instead of relying on information submitted to them by the home, there would be less visits to the ER!
      Doctors visit the LTCH once per week for less than an hour to sign prescriptions and attend short Care Conferences.
      While it is true that residents can come back from hospital worse than when they left, they do receive proper medical attention and directions for staff when they return.
      As for a cocktail of unfriendly poisons, perhaps you are unaware that nursing homes in Ontario are now treating bed linens with unfriendly poisons…FIRE RETARDANT. This is NOT a Provincial requirement!
      Chemicals in Fire Retardant are known to cause a myriad of health issues including cancer. Perhaps another reason they end up in ER.
      I think it is a case of frustration with the lack of proper medical attention and care for the elderly than “Culture amongst the family” that is the problem.

    • Trish Rawsthorne says:

      Appreciate your comments and insights into problem especially the prescribing of seriously harmful drugs inappropriately without evidence of efficacy in the elderly population as well as the Black Box warning to not prescribe these drugs. I would hesitate to guess that the most under-reported cause of death is due to Neuroleptic Malignant Syndrome (NMS), or unrecognized adverse events such as tardive dyskinesia and akathisia which are incorrectly labelled as undesirable behaviours.

      I agree that the culture is a huge impediment to quality care and this could be changed if the model of care was changed to a more person-centered social model of care and ageing was not treated as a disease. From my earliest exposure to nursing homes in the early 1970’s, I realized that the model of care was wrong and the treatment of the elderly was deplorable. I would say to some minor degree the creation of the Residents Bill of Rights may have afforded some more autonomy,but recently the WHO disagreed especially when dealing with those with any form of cognitive impairment and the significant loss of autonomy they suffer.
      Change the model of care, change the stereotype of the elderly and the single-mindedness of nursing homes as the answer. Open the doors to creative methods of serving, caring and maintaining the dignity and independence of those who need help. We are innovative people, and they deserve better.

  • Kathy Pearsall says:

    I agree with Denyse. The studies have been done; it’s the leadership that’s missing. I am tired of all the industry-government-research and so-called advocate talk of a ‘culture change movement’ that is apparently taking place. Baloney! The bottom line is that for-profit nursing homes have significantly higher rates of mortality and hospital admissions (JAMDA, Oct 1, 2015 16(10):874-93) and this supports many previous studies. It therefore behoves us to stop building for-profit facilities. Currently, for-profits make up 60% of Ontario’s nursing home sector and their expansion continues. – Kathy Pearsall, Concerned Friends of Ontario Citizens in Care Facilities

  • Denyse Lynch says:

    The problems mentioned have existed for years. At least over the last 15 years while I was a caregiver for my dad. They’ve just become much worse and sadly, the health care system habituated to things being as they are. This is the new normal. We’ve known for years the population was aging, living longer, would have dementia, Alzheimer’s and be experiencing multiple chronic conditions. Our government(s) knew this was coming.

    Years ago, a coordinated, collaborative approach with all MOH Provinces getting together to share their senior population situations/circumstances, challenges, and sharing ideas on providing more effective care, best practices, would have been a strategic approach. What we have are provinces who have been experimenting with different models of senior care and we (constituents/caregivers) read about them in the media or on web sites like this. When are successes going to be shared so other provinces can learn and adapt the successful models to their particular situations/circumstances?

    Ontario has had at least 2 committees (Sharkey report, 2008 & another in 2011) commissioned by Ms Deb Mathews on the state of senior care/needs in the community and in LTC. Each report showed the “same findings” and provided the “same recommendations”. Solutions are and have been available. The question is where is the coordinated approach of the competent governments, MOH leaders, health provider leaders and service providers to initiate the implementations of the ACTION PLANS that best meet each provinces’ needs? Why studies, recommendations for years and years with no change except for the worse? Poor planning, incompetence, unwillingness?

    Extremely tired of the “talk” especially the phrase “we take seniors’ health care very seriously”. Please, announce what the plan is, who will be taking accountability for overseeing the implementation, when will it start to be implemented, how the plan actions will be measured/monitored for effective outcomes, how and what training will be required by those delivering the plan to seniors, how will their competencies be evaluated against the standards they will be required to meet, who will be accountable, responsible for ensuring the right people are in the right job, and that there is a sufficient number of them, who will ensure the people delivering the plan will be coached to ensure performance objectives met, what measures will be taken when people/organizations don’t measure up to agreed upon standards, who will ensure and be accountable that appropriate consequences/actions are taken when individuals cannot perform to standards, what will the consequences be, who will ensure the health providers’ care and/or services are communicated in a timely fashion to all a patient or resident team providing care, including their caregivers, who and how will caregivers be supported, educated about their role and potential responsibilities that accompany caregiving.

    With all aspects of the health care system’s commitment to deliver “quality care, quality services,” its communications, systems, policies, procedures, recruiting, training, recognition, compensation, promotion elements must be designed and aligned in order to transform our current methods of delivering quality. Simply put “quality is conformance to standards”. If we can’t measure it, by the standards we set, we can’t monitor it for effective/efficient outcomes and of course, then we can’t change the standards.

    • Peter G M Cox says:

      What an (extremely) articulate summary of the problem(s) –
      1. They’ve existed for many years
      2. “We” keep studying them “to death”
      3. Repeated (very) generalized reassurances are issued
      4. It doesn’t seem to lead to a coherent strategy
      5. Still less does it lead to effective execution
      Of course, the same could be said about healthcare in general, not just nursing home patients

    • angela Silvers says:

      The issue is that a new care model requires change and facilities and PCPs are resistant. I am an NP with Optum . We are a company of nurse practitioners that have been contracted by United Health Care. We are an insurance benefit for the members. We are assigned to nursing homes and round on our members regularly. We have a treat in place model and are available to the member 24 hours a day 7 days a week. We try and collaborate with the PCPs and the facilites. We call the PCP with any changes to the member. In addition we call the families with any changes. We are not an added cost nor do we bill. The pcp can see the member the same day and bill as their norm. We have been around for almost 30 years and recently came into NE Ohio. We have had huge pushback by the facilities and the PCPs. It is hard to understand why any nursing home or busy PCP would turn down the extra help for their patients. We continually see our members get sent to the ED for UTI’s , change in mental status etc and we were never called. We could have treated the member in the facility, safely. We can round on that member daily and keep a close eye on them to see if they are responding well to the treatment. We have to ability to order in house diagnostics , IVF and IV antibiotics. While we have had some buildings that welcome the help for the most part they prefer to send to the ED.

      • Trish Rawsthorne says:

        I am glad that i stumbled upon this debate as I was searching for interesting material to post on my Facebook page Canada Nursing Home Reform. I have nothing but admiration for what you are doing. I think the problem with facilities not accepting help has more to do with the entrenched model of care – that being the medical model, as well as the general feeling ascribed by various professionals including MDs and Physiotherapists, and nurses – “they are old and why should we be expending our health care dollars on them” this came from a recent article in out local newspaper from a medical professional. Instead I would think that under a social model of care, and an different type of housing system as the Scandinavian countries use for elder care, what you are doing would wholly supported.
        If I had the opportunity I would employ only services such as the one you belong to as well as physiotherapist, nutritionists and occupational therapists, and train and employ “excellence in care giving experts” all under the social model of care.


Wendy Glauser


Wendy is a freelance health and science journalist and a former staff reporter with Healthy Debate.

Maureen Taylor


Maureen Taylor is a Physician Assistant who worked as a medical journalist and television reporter for the CBC for two decades.

Debra Bournes


Dr. Debra Bournes is the Chief Nursing Executive and Vice-President of Clinical Programs at The Ottawa Hospital.

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