A Step in the Right Direction: Why Nurses Should Lead the Shift to Providing More Community-Based Care

Photo Credit: Mark Nowaczynski

A Step in the Right Direction: Why Nurses Should Lead the Shift to Providing More Community-Based Care

As you get older, you will likely develop some chronic conditions, become more frail, increasingly use hospital resources and end up in a long-term care home, right? Wrong! As our population ages, there will actually be more older adults wanting and receiving care right in their homes and communities. As the Clinical Coordinator and Registered Nurse of the Independence at Home Community Outreach Team, I have seen the benefits that many older patients gain from this new shift in health care delivery from hospital- to community-based care.

Why the shift? Well, in examining the anticipated growth of our ageing population, it really makes a lot of sense. Today, 17 per cent of Canadians are over the age of 65; in the next two decades the size of that age group is expected to double and the number of Canadians aged 85 and over will quadruple. By 2030, 1 in 4 Canadians will be at least 65 years old. These growing numbers are important because, traditionally, older Canadians have been the most frequent users of the health care system. Shifting the primary setting of health care to the community can reduce the costs of health care.

Indeed, it’s not just about saving money, it’s about what matters to older Canadians too. Most older adults say that receiving care in their communities where they live is actually what they prefer. The vast majority of older adults would like to live at home throughout their later years – and right now, 93% do! Rather than accessing health care resources to treat individual issues as they arise, older adults are increasingly seeking proactive, regular care to meet their longer-term and chronic care needs.

So, what can be done to support older adults at home? While caregivers play an invaluable role in supporting older adults to live healthy and independent lives, there are opportunities and, indeed, the need for health care professionals to actively join in and participate in providing care in the community. This is especially true given that many older adults live alone, which can make caregiving a challenging task for their loved ones, particularly if they do not live close by. Canadians are actually more likely to live alone as they age and, potentially, become frailer. Over one-third of Canadians aged 75 and over lives alone, while about half of those aged over 85 live alone. Community nurses – and the interprofessional teams they work in – can do a lot to join in to support the health, well-being and independence of older adults.

To meet the needs of a rapidly ageing and increasingly community-dwelling population of older adults, various health care providers, such as physicians, psychiatrists, pharmacists, physiotherapists, occupational therapists, social workers and nurses will have to meet them where they are – at home – especially as the number of those becoming homebound continues to increase as well. This is exactly what the Independence at Home Community Outreach Team does on a daily basis. Our Social Worker, Pharmacist, Geriatrician, Home Care Coordinator and I conduct home visits to work with patients and caregivers towards independence and safety at home. We learn so much about our patients by being able to meet with them on their “turf.” A look at their blister packs and in their fridges as well as observing where they live and how they navigate within their own homes, provides me with a lot of insight into an older adult’s overall well-being, desires and goals. Let’s not forget the efforts patients often have to exert in order to get out to an appointment, such as organizing transportation, and keeping track of when and where their visits will be happening. Community-based care greatly minimizes these obstacles by bringing care right into the home.

My role on this team is, like all nursing work, both a great privilege and responsibility. I have a fantastic team that I work with that values my specialized nursing expertise and also enriches my knowledge which, in turn, makes me a better nurse for my patients. We meet for weekly rounds to collaboratively construct creative solutions, explore relevant supports, and discuss patient-centred ways for navigating, educating and advocating for our patients and their caregivers. With each team member’s wealth of resources and expertise, we have been able to come together with the patient and their existing support system to make meaningful contributions.

Home Care Ontario says that nurses play active, integral roles in home care teams and that they will need to continue to be part of home care teams in the future. The shift to community care is strengthened with the proactive and preventive care that nurses provide to their patients and caregivers, helping prevent avoidable hospital and long-term care use.

Nurses are knowledgeable, compassionate, and dedicated professionals who can, and do, make a difference every day. I am very lucky to be able to do this through my work with the Independence at Home team. By encouraging nurses, with the support of interprofessional teams, to provide care to older patients where they live, we can enable more active, healthy and independent living among community-dwelling older adults.

Date modified: 2017-05-05

About the Author:

Agnes Kulinek, RN

Agnes first discovered the grey and exciting world of geriatrics when she volunteered with a Seniors’ Population Panel. Agnes maintained this focus while completing her Masters of Nursing at University of Toronto and subsequently working as the first Transitional Care Specialist at the Toronto Western Hospital where she supported vulnerable patients in their return home. Agnes continues her passion for empowering, preventative geriatric care as the Registered Nurse and Clinical Coordinator with the new Independence at Home Community Outreach Team. She enjoys an environment where there is never a shortage of challenges and creative, collaborative solutions.

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