Reta’s Story  (a contribution of Judy Smith, Reta’s daughter-in-law)

In our report last week we confronted the fact that patient-centred care can be a reality or a dream. As you know, RNAO has been advocating for person-centred care for years. Our Person-and-Family-Centre Care Best Practice Guideline (BPG) is core to our work with the Ontario Health Teams (OHTs) that are Best Practice Spotlight Organizations (BPSO). RNAO’s work with Ontario Health Teams on person-and-family centred-care was at the centre of a BPSO OHT four hour meeting a few weeks ago, and here we have another glimpse, arising from that meeting, on what person-and-family-centred care looks like from the field. The following is a contribution from Judy Smith, who shares a story about her mother-in-law Reta.     

Reta is a 96-year-old, cognitively sound resident of an independent living retirement home. She has lived in the home for almost nine years. A widow for the past five years, Reta has suffered from arthritis and gout in multiple joints, a torn rotator cuff in her left shoulder, and uses a four-wheel walker for mobility. For the past few years, her greatest fear has been falling.

On March 24, 2019, Reta fell and was transported to Southlake Regional Health Centre by ambulance. She was diagnosed with a fractured right ankle and required an air cast. Her left ankle was also possibly fractured. Reta was admitted to acute care, and then transferred to the Reactivation Care Centre (RCC) for ongoing assessment and rehab.

All Reta wanted was to go home.

I was aware of a pilot program called Southlake at Home and asked that Reta be considered for admission. The longer she was in hospital, the higher her chances of becoming delirious, falling, becoming incontinent or catching a hospital-acquired infection. Thankfully, she was accepted and was discharged within two weeks of admission.

The hospital’s rehab team worked with Reta on her goals, and what she would require for a safe return home. When her discharge day came, the team provided a package of materials describing the services she would receive.

Although I am not Reta’s substitute decision-maker, I am the person she wants the care team to contact with information and questions. I received a call from SE Health, which administers the pilot program. The call was an introduction to their services, including details on the equipment that would be delivered to the retirement home. I was informed that a nurse case manager would visit Reta on the day of discharge to get her set up. I received another call when the promised equipment had not been delivered, accompanied by reassurances it would be there before Reta was home.

This is an example of the good communication I came to expect from the team. It was essential to begin building trust, as was the 24/7 phone number we were given to call if there were any concerns.

Helen was Reta’s nurse case manager. She visited that first day, determined Reta’s goals, and asked the family about ours. Reta already met her goal of being at home. In the longer term, she wanted to walk to the dining room, using her walker independently. She also wanted to attend her 95th birthday party, which was an outdoor event.

Reta received morning and evening PSW support. Physio also visited to start work on her mobility, adjusting the height of her walker to ease pain in her shoulder. OT did a home safety assessment among other checks. And the team worked with the family and the retirement home to ensure Reta was able to eat in the dining room.

Three weeks into the program, Reta felt comfortable cancelling her evening PSW as she was able to get into bed and remove the air cast on her own. Helen continued to visit daily to monitor progress, review the team notes and update the family when necessary. We were encouraged to call the team or leave notes if concerns arose.

Mid-way through her journey, Reta received a phone survey about her impressions of the program. The family was also surveyed. One question that I appreciated: “How are you doing as a caregiver, what do you need?”

Reta continued to meet her goal of walking with supervision to the elevator and dining room. Eventually, she started doing it on her own.

Southlake at Home provided a different and more person-centred care model that focused on Reta’s goals, with consistent communication, smooth transitions, warm hand-offs, evidence of team communications, and family support. There was one shared assessment and chart, accessible to all team members, including primary care. Trust was established early, and Reta was afforded the dignity of setting, altering and meeting her own goals.

Reta and the family feel she was able to have a short hospital admission and return to her home faster because of the Southlake at Home program. In our eyes this was a successful pilot that needs to be continued and expanded.

Reta is still in her home and continues to direct her own care and finances.