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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