Integration of Nurse Practitioners into the Rehabilitation and Reablement (R&R) Care Team for Vulnerable Seniors | MEKTU | NB-IRDT | UNB

Global Site Navigation (use tab and down arrow)

NB-IRDT

Integration of Nurse Practitioners into the Rehabilitation and Reablement (R&R) Care Team for Vulnerable Seniors

Lead organization: Government of New Brunswick, Department of Health

Principle investigator(s): Evangeline Hallam

About the project:

The issue

The R&R program provides seniors with intensive, short-term care to help them restore their independence and remain at home following a hospital admission or event in the community. This model of interdisciplinary health care is integrated with social services to support patients who are at home and at risk of hospital admission or in hospital but no longer in need of acute medical care. 

Patients in this program who experience an urgent health issue or event at home might have difficulty reaching their primary care provider (attending physician or nurse practitioner) for timely advice and intervention. If their medical needs are not met and managed in the community, these patients often need to go to the emergency room and/or be readmitted to hospital. Preventable returns to the emergency room or readmission to hospital can place additional burden on the hospital system and cause stress to the patient.

The importance

R & R patients requiring the emergency room and/or be readmitted to hospital creates strain on the emergency room and hospitals and is not always in the best interest of the patient. Many of these patients are frail and have a number of geriatric syndromes such as cognitive impairment, functional decline, polypharmacy (multiple medications) and falls.

What makes this project different

This project will integrate nurse practitioners into the Rehabilitation and Reablement (R&R) service offered by the Extra-Mural Program (EMP). By integrating nurse practitioners into R&R, the nurse practitioner will be able to see these patients in their homes or special care homes for assessment and management. Additionally, the nurse practitioner will be able to provide support and advice to the EMP interdisciplinary team.

Anticipated impacts

By enhancing the current model of care offered by the R&R service, it is anticipated that more patients will be admitted to the program and that more patients will benefit from this service in their homes, thereby avoiding the need for unnecessary ED visits, hospitalizations and strain on the acute care system.

Return to MEKTU project list