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Physician and Practitioner Fact Sheet
Mississauga Halton CCAC
Rapid Response
Nurses (RRNs)
Patients with complex
care needs often require
more constant care
to ensure they thrive
out of hospital and
are not readmitted.
By managing those
patients’ care needs
more effectively, our
entire health system
benefits.
Mississauga Halton
CCAC Rapid Response Nurses (RRNs) provide
complex patients with an intensive level
of assessment to ensure medications are
taken as instructed; follow-up doctors’ visits
are made and kept, and ongoing clinical
assessments continue through constant
monitoring by a consistent Rapid Response
Nurse for up to 30 days after leaving hospital
or after referral from a community service
agency.
Partnering for better
patient care
We partnered with Trillium Health Partners,
Halton Healthcare Services and community
support services agencies to identify
patients who may benefit from the one-onone, intensive care coordination that our
Mississauga Halton CCAC Rapid Response
Nurses (RRNs) can provide.
RRNs help patients by:
• Keeping at-risk adults and seniors
at home by providing support and
education to patients and their
caregivers.
• Ensuring patients are confident that
their discharge from hospital will be
successful.
• Helping patients understand and
participate in creating a health care plan
that works for them.
Eligibility criteria
Our highly skilled, experienced registered
nurses support adults and seniors who have:
• Complex care needs
• Poorly managed chronic diseases such as
COPD, CHF, diabetes, cardiac disease
• Multiple admissions to hospital,
or frequent visits to emergency
departments or urgent care
• Difficulty managing medications
• Fragile care support
www.healthcareathome.ca/mh
www.mississaugahaltonhealthline.ca
Scope of practice
Rapid Response Nurses (RRN) visit each patient in their
home within 24-48 hours of discharge from hospital
or referral from community service agencies. They
complete a full assessment, assist with medication
management and work with each patient to educate
them about their specific health issues.
• The RRN assists the patient for up to 30 days
to reduce the risk of readmission to hospital or
avoidable emergency department visits.
• The average length of service is 2-3 visits.
• Before discharge, the RRN will connect the patient
with community supports, such as clinics, that
they require to help them in with ongoing disease
management.
Roy’s story
Roy has multiple health
conditions: congestive heart
failure, diabetes, COPD and
hypertension.
Lynda Amodeo-Thomson,
a Mississauga Halton CCAC
Rapid Response nurse,
met with Roy before his discharge from hospital and arranged
to visit him at home the following day.
During that first home visit, Lynda re-assessed Roy’s needs
and ensured he was taking his medications as instructed.
Lynda also helped Roy connect with his family doctor to
arrange follow-up appointments.
Over the next 30 days, Lynda continually assessed Roy to
make sure his care plan was meeting his needs and that
he was taking his medication and visiting his doctor. She
helped Roy identify his signs and symptoms to help him
better anticipate when he might be in medical trouble. Lynda
also taught him ways to manage his health to prevent rehospitalization.
Since working with Lynda, Roy takes a much more proactive
approach to his health. He monitors his weight, checks labels
on cans he buys to monitor his sodium intake, and records his
weight, fluid intake and what he eats daily on the computer to
send to his family physician.
Roy wants to stay out of hospital and avoid repeated visits to
the emergency department. “It is great to work with Lynda.
She is a good teacher. And physically I am feeling better.”
www.healthcareathome.ca/mh
www.mississaugahaltonhealthline.ca
How do I refer a patient to
the Mississauga Halton CCAC
or speak to my patient’s care
coordinator?
Contact us:
• Call 310-2222 (no area code
required)
• Speak to a Mississauga CCAC
care coordinator in your
hospital (located in all sites of
Halton Healthcare Services and
Trillium Health Partners)
• Fax in a referral to the
Mississauga Halton CCAC
(905-855-8989)
Find out more about the
Mississauga Halton CCAC and how
we can help your patients:
www.healthcareathome.ca/mh
www.mississaugahaltonhealthline.ca
The Mississauga Halton CCAC is
open seven days a week, 365 days
a year.
August 2015