Imagine you are an elderly patient with multiple health issues, but you don’t have a primary care provider to check in with when you’re experiencing a new health concern or require a medication renewal.
Or imagine you are a new parent welcoming your newborn into the world. You feel safe and cared for while on the Maternity unit but once you and your baby are discharged, you don’t have a consistent care provider to follow up with for help with feeding concerns or to ensure your baby is meeting growth milestones.
For many people in our communities, this is a reality. They are called “unattached patients” and they don’t have a primary care provider like a family doctor or nurse practitioner to rely on for their basic health care needs. They often seek care in an inappropriate setting such as an emergency department, or worse, don’t seek care at all, leading to deteriorating health.
During the June 28th QHC Board of Directors Meeting, the Board recognized two very special partner organizations for their efforts in providing much-needed care to unattached patients. The Board of Directors’ Values in Action Award is usually presented to a QHC team or individual who goes above and beyond in their role, but this month, the Board was pleased to recognize two exceptional partners – Belleville Nurse Practitioner-Led Clinic (BNPLC), and Gateway Community Health Centre.
These two organizations have teamed up to help support unattached patients in our communities through a virtual care program. The Hastings Prince Edward OHT Virtual Support for Unattached Patients program has supported over 1,282 clients with 3,649 visits in six months. Many of these virtual visits have resulted in patients being diverted from QHC’s emergency departments, or have prevented potential hospital admissions or readmissions.
“Patient flow has been a huge challenge for our hospitals, with the pandemic exacerbating these concerns,” said Lina Rinaldi, QHC Vice President and Chief Nursing Officer. “We often have patients using our emergency departments for primary care concerns like ear infections or medication renewals because they have nowhere else to turn. Gateway Community Health Centre and Belleville Nurse Practitioner-Led Clinic are helping to solve this issue and are showing a real desire to help the system and to ensure people get the right care, at the right time, in the right place.”
Karen Clayton-Babb, Chief Nurse Practitioner and Clinic Director of Belleville Nurse Practitioner-Led Clinic, explained that many of the clinic visits were coordinated between QHC and the clinic so that newly discharged patients had access to timely follow up care, reducing risk of readmission. Also, many individuals seen in the clinic were identified as overdue for preventative care screening and, through the clinic, some received abnormal results, triggering referrals to appropriate specialists. She said, “one cannot help but wonder at what stage these diseases would have been caught, if it was not for access to the virtual clinic.”
The Belleville Nurse Practitioner-Led Clinic has also received funding to provide follow up care to QHC newborns during their first two months of life. That program is still being established, but in the meantime, BNPLC has accepted more than 100 unattached babies from QHC, many whose siblings and parents are also unattached patients and received care or immunizations from the clinic.
“Newborns are supposed to be seen by a primary care provider within 72 hours of discharge,” said QHC’s Tracey Giles, Program Director of Maternal Child and Mental Health. “Sending newborns to walk-in clinics can be fragmented care for these vulnerable patients, so having BNPLC following unattached newborns for their first two months of life provides peace of mind that there’s a plan in place and the newborns are getting the care they need once they leave the hospital. We hope there will be an opportunity to extend the care window beyond the first two months of life.”
“These innovative partnerships are a prime example of what we can do at a local level to meet the escalating health care needs in our communities,” explained John Kearns, QHC Board Treasurer, when presenting the award. “None of us can do this alone. We need to work together to find local solutions that have a big impact. We thank these two incredible partners for their desire to make a difference and for providing the people in our region an additional option for primary care. Thank you also to all those at QHC who are working in collaboration with our partners on these meaningful initiatives.”