REPORT OF THE SUBCOMMITTEE OF THE EAST SHORE HEALTH SOCIETY
Plus a letter from Mary Donald, resident RN for decades
This document relates to a serious concern about the substitution of an irregular provision of nursing services to the East Shore of Kootenay Lake for a long-standing, regularized, and highly valued service.Until March 31st of this year, a health nurse was available four days per week (21 hours). The nursing position was eliminated by Interior Health (IHA) that claimed the demand for home health services did not justify that amount of time. Ms. Cheryl Whittleton of IHA indicated that “appropriate home health nursing services” could be supplied from Nelson on an outreach basis. It was determined that a nurse could travel to the East Shore once or twice a week based on demand/request. Under these new arrangements, East Shore residents would be required to phone a specified number and make an appointment for a future date. The nurse would then travel from Nelson to Crawford Bay on the agreed-date.
This report argues that the change in the provision of ‘outreach’ nursing services is sorely inadequate to meet the needs of the residents of the East Shore and ignores IHA’s mandate to promote prevention of the development of chronic disease through community-based early intervention and counseling related to diet and lifestyle changes, and makes the case that IHA should reconsider the decision to eliminate the nursing position.
Several recommendations are made to the Board of the East Shore Health Society for follow-up action.
As stated in a document available on the Interior Health website, “…patterns of health and health care service use vary across geographic areas. Geography can determine common experiences and opportunities that affect health status. The economic prosperity of an area determines employment options—and it is understood that both income and type of work influence health status. Geography can also have a more direct effect on the use of health care services. Some of this may be due to local custom—the way people in a particular area understand their health and seek health care services as a result. But part of the variation also relates to the availability of services. For example, people in rural areas have to travel longer distances to access certain types of services or physician specialties which may influence the rate at which they use those services.”
The health issues associated with living in a rural area are well documented. Rural Canadians are more likely than urban residents to:
live in poorer socio-economic conditions;
have lower educational attainment;
exhibit less healthy behaviours
have higher overall mortality rates than urban residents.
“People living in rural communities generally need to travel longer distances, and often on more dangerous roads, for work, shopping and other reasons. Not surprisingly, injuries and death due to traffic accidents are much more common in rural areas.”
“Those living in the most rural areas are the most disadvantaged. They are more likely to die from injuries, heart disease and diabetes. Life expectancy is lower in rural areas compared with urban areas.”
Bushy (2000) states that “rural residents are older, describe themselves as ‘less healthy’ and have more chronic health problems than urban residents. However, they also tend to seek medical care less often than urban residents. “ She goes on to point out that large numbers of younger people are leaving rural areas and migrating to urban areas to find work. This leaves behind older adults and other vulnerable residents, thereby placing even greater strains on healthcare systems.
“Healthcare reform is changing where care is delivered and the types of services rendered to clients (patients). More precisely, there is a shift from acute in-hospital care to community-based services. Provision of care primarily for acute medical conditions is being replaced by ambulatory care services. Correspondingly, the emphasis is on promotion of health and prevention of illness in individuals and communities.”
Disease prevention and health promotion are recognized as important issues in both acute and community-based primary health care settings. However, “what is less clear is whether conventional strategies, mostly developed by urban program planners for urban residents, are equally effective in rural settings”. The results reported in this study of the health of rural Canadians, which included such factors as higher proportions of smokers, lower consumption of fruit and vegetables and higher proportion of individuals who are overweight among rural residents, suggest that there may be potential for better outcomes with “rural-friendly approaches in disease prevention and health promotion.”
SITUATION ON THE EAST SHORE
The East Shore of South Kootenay Lake is a 60 km long region stretching from Kuskanook in the south to Riondel in the north. The region contains some 2000 permanent residents, swelling to over 4000 during the summer months. In addition, hundreds of motorists and passengers travel through the area every day in the summer via Highway 3A and the Kootenay Lake Ferry. During the winter months, Highway 3A is the alternate route for east-west traffic when the Kootenay Pass on the Crowsnest Highway is closed and, on these occasions, there are many additional people in the area.
Some years ago, East Shore residents had access to a physician who maintained a private practice in Riondel. When that service was no longer available, the East Shore Community Health Centre (ESCHC) located in Crawford Bay was developed to provide services to residents of the Kootenay Boundary Health Service Area. On Tuesdays, Wednesdays and Thursdays, a physician travels from Nelson to provide clinic-based medical services. Outpatient laboratory services are made available on Wednesdays from 7:30-11:30, and a counselor and a physiotherapist are available throughout the week. Until earlier this year, a 21 hour/week nursing position was also in place; that position, as described earlier, was eliminated in March of 2013 and is the focus of this report.
The East Shore is certainly a rural region and is considered ‘remote’ because residents must travel to Cranbrook, Creston, Nelson or Trail for treatment of any serious injury or illness.
This area of the Kootenays has a high proportion of residents with relatively low socioeconomic status. For example, the riding is reported to be the second poorest in BC, and the Stats-Canada 2006 Census data indicates that residents in the Nelson-Creston region had an average household income which was only 73% of the BC average. The proportions of Nelson-Creston households that have annual incomes below $10,000, $10,000-$19,999, $20,000-$29,999, $30,000-$39,999 and $40,000-$49,999 are higher than the provincial proportions. The proportions of Creston-Nelson households in the income brackets above $60,000 are consistently below the provincial proportions (see Appendix C)
Many residents along the East Shore are older adults. The 2006 Census reported that 45.5% of the residents were over the age of 50 compared to 37.1% provincially. As is often the case with seniors, some live alone and a sizeable proportion of these people are either unable to drive or have some form of driving restriction. In the complete absence of public transit, they are dependent on family and friends to drive them to medical appointments. The loss of an on-site community-based health nurse has been particularly burdensome to this group.
Citizens along the East Shore who are concerned about health and safety have banded together to form various groups to develop strategies to deal with emergencies. An ambulance service is provided in Riondel but is struggling to find adequate numbers of staff. First Responder groups exist in Riondel and Boswell. The Boswell and Area Emergency Volunteers (BADEV) are a particularly active and well-supported group who are keen to partner with and support First Responders in other communities to provide emergency coverage for the East Shore. In other words, East Shore residents recognize the problems and risks of rural living and do what they can to mitigate these risks.
The announcement that the East Shore nursing position was to be eliminated and replaced by a nurse who would travel from Nelson on an “as needed” basis caught residents in Riondel, Crawford Bay, Gray Creek and Boswell by surprise. As described earlier, the sudden loss of their long time physician some years earlier had triggered a lobbying and negotiating effort with IHA that resulted in the creation of the Crawford Bay East Shore Community Health Centre. This is a much-appreciated clinic that has served us well. The nurse position was filled by a local resident who is a Registered Nurse and who spent 4 days a week serving the needs of the population. A description of the kinds of challenges, opportunities and accomplishments by the RN is provided in Appendix B and illustrates a definite need for the service.
The spokesperson for IHA, Ms. Cheryl Whittleton, made the claim that there was insufficient demand to justify the 21 hours per week nursing position. Unfortunately, that claim was not backed up by the release of any data or report of any supporting study of the situation. This lack of transparency and the failure to consult with residents naturally triggered a negative reaction in the community.
East Shore residents have responded in a number of ways to a genuine reduction in nursing services. A letter-writing campaign was initiated early on and has resulted in hundreds of letters being sent to IHA and to other local authorities. In response to hundreds of letters received in her office, MLA Michelle Mungal reported that she met with the CEO of Interior Health, Dr. Robert Halpenny, who provided assurance that “Home Health Nurse services will not be diminished on the East Shore.” Specifically, Dr. Halpenny assured MLA Mungal that “the proposed personnel changes would not lead to diminished health services on the East Shore”, and that “no one will be required to travel to Creston or Nelson for these services because they are home-based services.”
When it was apparent that there would be no satisfactory response to the letter-writing campaign, a rally to protest the nursing position loss was held at Kootenay Bay ferry landing on July 7th, 2013. An article describing the events and purpose of the rally was posted in the East Shore MainStreet and includes several important points:
“There is no substitute for having a resident RN on the East Shore who is intimately familiar with the needs to the people who live here.”
” No one who spoke was willing to accept the Interior Health Authority’s argument that paying an itinerant nurse four hours of travel time to deliver three hours of services was cost efficient.”
“As one senior pointed out, rural areas had community health nurses even during the Great Depression. As Canada’s population ages, health authorities need to do more than pay lip service to the value of preventative medicine and quality home care.”
Finally, a subcommittee of the East Shore Health Society was created to consider the matter of the alteration in nursing services and to report back to the Board with recommendations for action.
IMPLICATIONS OF THE COLLAPSE OF NURSING SERVICES PROVISION TO THE EAST SHORE
The Subcommittee members are gravely concerned first and foremost about the quantity and quality of care that can be provided, however well-intentioned, by a nurse (or, as seems possible, by a roster of nurses) who travel from Nelson on an appointment basis. The reasons for this concern should be obvious, but include the following:
Only a fraction of the reasons for consulting/needing a nurse are predictable and easily managed on a future appointment basis. Since the ESCHC has a physician in attendance only 3 days a week and much of the available physician time is taken up by previously scheduled appointments, minor ‘emergency’ treatment could not be managed. To be able to have small procedures done by an on-site nurse at the Clinic saves patients of 3-hour (minimum) round-trip commutes and is especially helpful to children and older adults. Even when an attending physician has the time to treat a minor emergency, scheduling the needed follow-up care/treatment over the subsequent days would be extremely problematic for a limited-time appointment-based nursing service.
Travel from Nelson to the East Shore means contending with the Kootenay Lake Ferry and its schedule (complicated by reduced numbers of crossings in the winter). Winter also brings irregular weather-caused closings of Kootenay Pass, resulting in long line-ups at the Ferry and the possibility of having to wait an additional 90 minutes for the next crossing. Twice a year, for a month each time, the smaller Balfour ferry replaces the larger Osprey for maintenance, and the consequent limited boat capacity during these times frequently extends the wait by an hour or more. Inevitably, this will mean fewer hours of actual on-site nursing care on the East Shore under the new nursing arrangement. Long-time East Shore residents know that lost nursing hours due to travel time was a major rationale for the establishment of the community-based nursing office on the East Shore in June 2001. What, we may well ask IHA, has changed?
IHA has clearly identified community-based preventative health care as a priority and the RN who held the position was certainly much involved with community groups, community health workers, local schools and groups in educating the public about lifestyle choices and healthy living. How will that important function be managed going forward via the current nursing arrangement for the East Shore?
The absence or irregular attendance of a nurse also impacts the operations of the East Shore Community Health Clinic. This will include such things as:
Physicians will spend more of their time at the clinic engaged in minor patient care like suture/catheter removal, burn and laceration care, dressing changes, injections, vaccinations etc., that could be (and were previously) managed by a nurse.
Physician-nurse consultations will be severely reduced by the limited availability of the nurse.
Follow-up patient care after minor surgery will be challenging to arrange even if the physician is concerned about possible infection or excessive bleeding, for example. This is predicted to necessitate more trips by patients to Creston or Nelson for emergency care due to post-surgical complications.
It is simply not possible to imagine that the new nursing arrangement would permit the previous level of service to East Shore residents as detailed by the RN who filled the position of community nurse at the ESCHC (see Appendix B). The implications of this observation are numerous as reflected in the comments of survey respondents.
Older residents fear that they may need to drive (or find/rely on someone else to drive them) to Creston/Nelson more frequently; they are also concerned about the increased costs of this travel.
Some residents are concerned that they will not be able to stay in their homes. This is especially the case for people with chronic illnesses.
The reduction in health service may well mean that there are fewer visitors to the East Shore, including summer visitors. One resident has already reported that a grandchild with allergies is no longer able to visit.
The need to call to make an appointment to see a nurse may well reduce the number of such calls—when an appointment must be made a week or more in advance, minor emergencies will need to be taken care of elsewhere.
The focus of services will be on acute care, leaving unattended a huge part of the health mandate—prevention.
The kinds of ‘facilitation’ of health services provided by the nurse who occupied the position until the end of March will no longer be easily available.
STANDARDS FOR HEALTH CARE SERVICE ON THE EAST SHORE
East Shore residents strongly support IHA’s statement on Home and Community Care:
The home and community care sector provides a range of publicly subsidized clinical and support services focused on individuals living in their own homes, and in other home-like settings through to, and including, the end of life. Services may be similar to those found in the acute or primary health system, including clinical nursing care, rehabilitation therapy, personal care and social work, or they may be unique to the community setting, such as case management, assisted living, home support, adult day services, and residential care services.
The goals of home and community care services are:
• To support individuals to remain independent in their community to the greatest degree possible;
• To facilitate clients’ transitions through the entire health care system;
• To enable choice, dignity and quality of life; and
• To provide caregivers with information, tools and support they need to be successful in their role.
We contend, in this paper and in letters and demonstrations, that the decision made earlier this year to replace an on-site, 4 day/wk nursing position with an ad-hoc, appointment based service provided out of Nelson represents a serious reduction in the quantity and quality of service available on the East Shore. In a recent phone call, Ms. Whittleton indicated that home health care could, in fact, be more than 21 hours per week depending on demand. This is not widely known in the community, and unfortunately the reality is a much reduced nursing presence.
We believe that the standard for quality nursing care includes a registered nurse or nurse-practitioner who:
Is available four days per week
Works from the ESCHC for in-clinic appointments but is also able to provide in-home care when necessary
Works in an interdisciplinary team with the employees of ESCHC
Emphasizes and implements preventative healthcare
Recently, health authorities across North America are moving to implement nurse practitioner positions in rural and remote areas where the care typical of urban settings is simply not possible. BC Ministry of Health has announced the creation of the Nurse Practitioners for British Columbia (NP4BC) program and provided funding for up to 45 new NP positions per year over the next three years to 2014/15. The SubCommittee urges the Board to strongly lobby IHA to apply for one of these positions which undoubtedly would be of great benefit to East Shore residents.
CONCLUSION AND RECOMMENDATIONS
The members of the Subcommittee concur with the views of many East Shore community members that the loss of a dedicated nursing position is a serious blow to healthcare services.
In eliminating the position, a representative of IHA claimed that there was insufficient demand for home health care services to justify the position. No evidence was supplied to justify this claim and the decision was apparently made without consultation with the community. In the interests of transparency the East Shore Community should be provided with the data to support this claim.,
At a minimum, survey responses by members of the community have demonstrated great concern about the loss of a valued service and have identified a number of incidents in which promised services were unavailable. In short, the promise made to MLA Michelle Mungal Interior Health Dr. Robert CEO Halpenny that “the proposed personnel changes would not lead to diminished health services on the East Shore” seems not to have been kept.
Conradson and Moon (2009, summarizing research conducted on walk-in centres in England, found that putting services in places where marginalized individuals reside does not necessarily ensure that they will ultimately decide to access such care. They conclude that providing care that is local is not necessarily the same as providing care that meets the needs of marginalized individuals in that location. This seems to have been the heart of the matter with respect to the lost “Home Health Position” which had a particular job description. The nurse who occupied that position was obviously providing many additional and much needed services that were not part of her designated ‘job’. Members of the Subcommittee believe IHA should consult with the community (and re-read Ms. Donald’s letter) and then design a position that suits the needs. Recommendation 4 below speaks to that suggestion.
The Subcommittee recommends to the Board of East Shore Health Society that:
The Board request from IHA the data that led to the conclusion that there was insufficient demand for home health care services to justify the nursing position.
The Board request from IHA data on the number of requests for appointments for nursing services since April 1st and how these requests have been met, including the number of hours per week a nurse has actually spent on the East Shore and the amount of travel time.
The Board request information from IHA about how it has met its obligations to promote preventative healthcare since April1 and, indeed, how this might be possible under the newly implemented provision for nursing services on the East Shore.
The Board request the restoration of nursing services on the East Shore to at least the level provided prior to April 1st or, failing that, a commitment from IHA to implement an independent review of the need for nursing services and how they can best be met.
The Board apply for one of the new Nurse Practitioner positions to meet the needs of East Shore Residents.
Karen Arrowsmith, Nancy Galloway, Carol Johnson,
Verna Mayers, Bruce Scott, Tom Wishart
APPENDIX A: Sample Survey Responses
The outcome of the new outreach approach to nursing service provision has implications on at least 3 levels—on individuals who need the service, on physicians working at ESCHC, and, in a broader sense, on the general population.
In a June 26, 2013 letter to East Shore residents, a committee of the East Shore Health Society asked for input about their experiences on having their nursing needs met since April 1st. In particular, residents were asked to respond to the following questions:
a) What health condition did you need nursing for? b) What kind of care did you need a nurse to give, and how often?
a) Were you able to get the nursing care on the East Shore? b) If not, what did you do?
Additionally, respondents were queried re their concerns about future nursing needs.
Representative examples of responses to Question 1 include the following:
Respondent # 1
1a “-post-operative care after abdominal surgery. Further assessment needed”
1b “To assess and change dressing daily.
2a “No, service had been discontinued
2c “ Caught ferry to Nelson & went to IH. They assured us they would come to Crawford Bay but did not.
Respondent # 2
1a “Persistent cyst which became infected. Persistent rash which also became infected.”
1b “Determine if a poultice could help, what kind, how often to apply, etc.”
2b “Tried various prescriptions & other remedies suggested by pharmacists without success”
1a “had surgery on face”
1b “needed to have bandages changed”
2b “drove to Trail”
“Lots!!!! Husband on dialysis. Bandage changes, tests, CSIL admin, etc. etc.”
“Testosterone injections twice per month for me. INR test for my wife @ different times”
“Had surgery on my face, needed to have bandages changed”
1a “Child had a rash”
1b “to tell me if it was serious”
2b “waited for rash to go away, child very uncomfortable, would have liked advice”
“broke my wrist, required 4 pins and surgery. Didn’t realize how severe it was, didn’t want to trouble doctor. Might have received treatment soon if a nurse had advised me.”
1a “”high blood pressure, apnea, prediabetic, high cholesterol, cataracts”
1b “to take my blood, monitor heart, etc”
Residents had these kinds of concerns about future nursing needs:
“As we age, concerns grow when health issues arise. We made an appointment for the health nurse to meet us at our clinic but I received a call cancelling this as we would have been the only appointment they were travelling for that day. We were nervous as the operation was recent and we were not accustomed to dealing with this. Eventually made a trip to Cranbrook to discover a further problem.”
“Could be anything since I have 4 different, serious illnesses: heart, lungs, Sjogren’s Syndrome, Raynaud’s Phenomenon”
“Nursing care needs to be available locally by a local nurse who knows the community and is readily available. The nurse is the glue that is critical in the service of the community. It is a huge mistake to have a distant service providing the care we need.”
“The elderly or chronically ill need to stay in their own homes, to die with dignity. My husband and I spend $20,000 yearly on health care—mostly travel—this will increase every time services on the east shore are reduced!”
“We have a desperate need for a resident RN who can see to people’s needs on an ongoing basis, and monitor longer term health issues.”
“There will be critical care needs that will not be met and deaths as a result.”
“That if something happened to my wife I wouldn’t be able to look after myself and would require help. Living on this side of the lake we require a car to get to help. If we got housebound we would be in trouble without a nurse to check on us. We want to live in our house as long as possible and be independent of needing help but as we age we know that without a nurse, ambulance this independence would not be possible.”
“Tell me please, how getting a nurse from Nelson to here & back, that this is saving money? Since I.H.A. has been in effect our medical costs have been elevated & have declined in treatment & service.”
“My husband and I retired to this area because there was a ambulance and health nurse available. We would like to live in our home together as long as possible. We believe that in the long run it would be less of a tax burden to the province if we could live in our own home and have a caretaker we could count on and know.”
“If I require surgery at a major centre, will they allow me to come home if there is no nursing available except for 1 or 2 days a week? What if the incision doesn’t heal as expected? How will I know whether I need to see a doctor?”
“grandchild has severe allergies; won’t come to visit now that no nurse available”
“I feel very vulnerable with my health needs, –suffering with pain and distress. The ambulance attendants are for emergencies only & I don’t want to tax the system. Often, I need an experienced medical person to just call or visit or know they are near.”
“If I have concerns about my family, but they are not serious enough to see a doctor. It would be nice to have a nurse available.”
“My wife was diagnosed with …. in 1991, the year after we moved here. She has had several amputations. Could have been discharged home sooner
APPENDIX B: Letter from Ms. Mary Donald Detailing Her Duties as Community Nurse
September 22, 2013
To the East Shore Health Society subcommittee:
You have requested an outline of what my duties as community nurse were here at the East Shore Community Health Centre.
I wrote my own letter of ‘protest’ to my manager last February regarding closing thecommunity nursing position and I thought forwarding excerpts of it would outline the work I did in this nursing position. I feel explaining my duties with some details/examples helps to better illustrate the picture. So, I will now include this below in italics, with a short summary after.
My role as a home and community nurse has been the one constant on the East Shore, being in the health centre the most days of all the health professionals (4 days per week), being able to coordinate care with the other health professionals, meeting with them in person or being reachable when needed. I meet with our doctors weekly, along with as needed, the physiotherapist, the hospice coordinator (especially important with an ongoing palliative), the massage therapist, mental health counsellor, the lab technician, even the public health nurse at times when she makes her visits, all contributing to a smoother flow of communication and care for clients. The Dr meetings are particularly important as things get done quicker and smoother as we don’t have to play telephone/fax tag (as other offices complain of) when I am trying to expedite client care. The patients win in the end.
I am also available, on site, as an obligated first responder as a case manager in adult guardianship cases, and I have been used in this context several times now, where timeliness is of the essence. I have been able to meet with our local Credit Union manager and halt financial abuse of elders on more than one occasion, for example.
I am on site to be able to accept short notice hospital discharges and new Home Support Clients needing the HARP (home hazard assessment reduction plan) done and Home Support Service chart in place before the client can receive service.
I have been available to do unexpected but pressing home visits for my elder clients whose health suddenly deteriorates and a health professional is needed to do an assessment because their doctor is not available. I have been able to have clients avoid unnecessary ER visits or hospital admissions this way (also very draining for the frail elderly to do the 3 hr round trip), provide relief of symptoms (for e.g. recently had a frail elder needing unexpected bowel care where I was able to intervene which also reassured distraught family). I have also been able to intervene where necessary and send my clients to hospital by ambulance, combined with communication with the receiving ER staff thus expediting their timely and informed reception, (only done because their Dr is not available, even by telephone. And these cases have occurred during my office hours.)
I have sent my clients to hospital who have developed serious bradycardia from heart block, others with exacerbated CHF, septicemia post cystoscopy, etc., all cases who were not aware of the severity of their conditions, who were all admitted to hospital. These would often be cases I would see on a Friday when there is no Dr at the health centre. I, of course, would strive to contact the clients’ Dr as well whenever possible.
And, I have been on the East Shore to attend to palliative clients who develop unexpected symptom management issues. Waiting for a Nelson nurse to arrive could easily be a 3-4 hour wait, depending how available they are and the ferry schedule.
One recent case in point demonstrates the advantage of having a nurse on site for the unexpected issue needing addressing. An elder resident signed himself out of KL hospital, but it was felt by the hospital transition liaison nurse that it was questionable that this man should be home alone due to serious self-neglect concerns. Home Support had been ordered by the TL nurse but they were unsure his home or mental state were suitable for receiving this service. I was asked by my supervisor to go to his home and assess it for cleanliness and suitability, do the HARP, and also assess his state once he arrived home. I was able to be there for this need, do the necessary assessments, and rule out HSS as suitable for this unfit client, and appropriately send him into a facility short stay bed via ambulance. As I live here, I knew who to contact in the community for support/information regarding this man, and I was able to stress to ambulance dispatch that timeliness was important and gave them the correct ferry to aim for, as evening was approaching.
Knowing the community resources, such as key local people in a variety of positions, saves a lot of time and energy when trying to deliver optimum care in general. Examples of this is knowing who to contact to do local housekeeping, driving, Red Cross equipment loans, local courier, Senior Citizen contacts, snow ploughing, church ministers, what the local stores provide or not, etc, the list goes on. These points especially impact our senior population. I have been called upon to have meetings with local groups to discuss a variety of health related topics. And it has been useful, to be on site for family meetings with concerned relatives of a client, often with visiting relatives whose timetables are limited. Our local retreat centre and school, the Yasodhara Ashram, has frequently discussed health related issues with me, and I have looked after many of their visiting cancer patients, often needing IV dome flushes between chemotherapy sessions.
We have limited lab time on the East Shore, with lab open only on Wednesday’s 0730-1030 AM. A nurse coming from Nelson cannot get here until 10:00 AM (as we are on a different time zone in the winter) and is not able to do multiple home visits for house-bound clients requiring blood draws. Recently I have had 3 house-bound clients requiring blood work: one end-stage cardiopulmonary disease, one a CVA, and one severely anemic and frail, as egs.
The East Shore is the only community in our Kootenay Boundary area without a hospital, nor even a resident doctor. Indeed, of our 3 visiting doctors, only one has an ongoing practice (in Nelson), so they are difficult to locate or communicate with. We are an isolated community and I, in fact, receive ‘isolation pay’ reflecting this fact. This makes the presence of our health centre even more important.
It is a 3 hour round-trip to and from Nelson or Creston, with the ferry schedule to also contend with. In the winter, with closures to the Kootenay Pass due to avalanche hazards, we get unexpected huge ferry line-ups with all the semi-trucks, and travel is next to impossible. The smaller Balfour ferry boat replaces the larger Osprey ferry boat twice a year for maintenance for a month each time, and one will often miss a ferry due to limited boat capacity unless one lines up an hour or more before sail time. In the past, when home care nursing was delivered from Nelson, many nurse hours were wasted waiting in ferry line-ups. This was one of the reasons a community nursing office was finally established on the East Shore in June 2001.
Due to this isolated and remote state here, our East Shore Community Health Centre has been hugely appreciated and well utilized by the population here. To be able to have small procedures done here saves people the 3 hour round-trip commute, especially helpful to children and the elderly. As the 3 Dr days (T,W,T) are frequently full or these events fall on a Friday, I have been able to help out here with simple one-time procedures such as suture removal, drain removal, catheter removal, burn and laceration treatments, dressings, injections, vaccinations, TB skin test follow-ups. Everyone comments on how grateful they are to not have to do the long trip to town for these simple procedures. Sometimes these cases become admitted to my program and I cannot know this until I assess them.
I am also called upon by the Dr’s to do dressing follow-ups a day or 2 after doing simple surgical procedures (toe nail removal, skin excisions, etc.) when they are no longer there and they have concerns with excessive bleeding or infection, for example, or client follow-ups for symptom management that they are concerned about. These visits can prevent hospital admissions. The doctors also call upon me to discuss wound assessments and treatment plans with/for them. Being here four days per week allows for some flexibility in being able to be available to meet together and with our common client over wound concerns and this again optimizes patient outcomes.
Having the RN on site has been very helpful for Home Support’s Community Health Workers (CHW’s) as well, and communication between us over client concerns is more accessible. We very much function as a team here and hold periodic informal meetings. One particular case stands out whereby having the nurse present helped a frail 90 year old lady’s wound management flow smoothly. She had an open cancer wound requiring daily dressing changes because she could not tolerate waiting longer due to high irritating discomfort. I was able to teach the CHW’s to do the dressings when I could not be there, provide the supplies as needed, and teach the CHW’s (sometimes in person and sometimes by leaving instructions) as her needs frequently changed and at times unpredictably. Dr Malpass was following this client and found her care to be ‘stellar’ under my guidance, and we helped her to have her best outcomes possible, and this was for over one year. This is an example of the team work that goes on here.
I am able to do patient teaching and provide resource material, and I have helped 5 clients to quit smoking, thus helping to save the health care system many dollars. I have been here to receive visiting health professionals, such as the Parkinson’s Association nurse, Lifeline Rep, CNIB rep, etc, who have passed on valuable information for me to share with my clients. My nursing office is a resource office serving our clients and staff.
The four day work week has been very beneficial. Often wounds need dressing changes at least twice/week and Tues and Fri have been a good schedule spread for this; Wed’s is blood draw lab day along with permacath and PICC blood draws; Thurs have been good for Long Term Care case management cases. High case management visit numbers is good because it monitors elders and keeps people out of crisis. The palliative clients and families benefit to have nursing available those four days and especially near their end days.
Since I started this letter, I read VP Andrew Neuner’s January 11, 2013 CIHS staff newsletter and can see that what he is envisioning in community health care is already happening here at the ESCHC, such as, “ a global shift to move health-care systems away from an acute-care focus to a team-based approach centred around community resources” and “establish the model for multi-disciplinary integrated care teams in the community.”
We have just such a health centre here where the various health professionals meet and work together as a team and we get things done. It has progressed well over the last few years and we are delivering very good health care to our clients. Having a community nurse as a part of this team is key to successful outcomes for clients. The nurse is the focal point in community care as she is the constant contact with all the disciplines. And a nurse on site has the flexibility to meet the unscheduled (and scheduled) needs of her clients, particularly pertinent for the frail elderly, and in preventing hospital admissions.
In short, as community nurse I was involved in both office and home visits with the following points:
much wound care (short term and long term), with consultations with regional wound nurse consultant as needed
IV flushes – post-chemo, PICC lines, permacath, IVAD domes, blood draws
palliative care including management/guidance of home deaths; pronouncement at times
referrals to and meetings with Hospice coordinator
catheter insertions and catheter care teaching
drain care and teaching
physical assessments, eg post cardiac and stroke events
written referrals to physicians re client concerns and follow-ups
meetings in person or phone with the various health professionals re client care
long term therapeutic injections (gold, B12, iron, methotrexate, testosterone)
home bound flu shots
home bound blood draws, some long term – eg on anticoagulant therapy
elder assessments for concerns over dementia, self-neglect, abuse, inability to cope, caregiver burnout, need to start Home Support Service, home physiotherapist, Lifeline, CNIB, Adult Day Program, respite time in facility, permanent facility placement, supportive housing guidance
elder guidance regarding Advance Planning (POA’s, Representation Agreements,etc.)
initiating Home Support Service in the home and compiling the Care/Service Plan; ongoing communication, education, trouble shooting, meetings with CHW’s
teaching of clients and their families on a variety of health issues, with resource handouts
meetings with families over client concerns and planning, esp in long term care matters
I also handled multiple telephone enquiries from the public, carried out ‘primary care’ tasks as previously mentioned in my letter (generally 2-4x/mo with more in summer), ordered supplies as needed, and assisted the physicians at times with on-site emergencies if I was available.
Mary Donald, RN
APPENDIX C: Education and Employment Profile for Nelson-Creston District