Rapid Response nurse helps patients self-manage chronic conditions at home

Dawn Siegers
Dawn Siegers is a 26-year nursing veteran and one of nine registered nurses from the Rapid Response Nursing program, which launched in 2017 by the Winnipeg Regional Health Authority.

Winnipeg Regional Health Authority
Published Monday, May 7, 2018

It's a safe bet that no health-care facility ever topped anyone's list of favorite places to visit.

That's especially true for people living with lung disease, congestive heart failure, diabetes, asthma, hypertension or other chronic conditions that can frequently land them in an emergency room, hospital bed or urgent care centre.

"The clients I see want to remain in their homes and they want assistance in identifying the resources they need to do so," says Dawn Siegers, a 26-year nursing veteran and one of nine registered nurses from the Rapid Response Nursing program, which launched in 2017 by the Winnipeg Regional Health Authority.

Targeted to clients being discharged from in-patient units, emergency departments, urgent care or clinical assessment units, Rapid Response Nursing is a short-term home care service that supports a successful discharge home with prompt interventions that can help avoid any unnecessary returns to hospital. These interventions may include ensuring prescriptions are filled and taken as instructed, follow-up doctors' visits are made and kept, and ongoing medical assessments continue during the crucial first few weeks after a client leaves hospital. The goal is to improve the client's ability to self-manage symptoms and remain safely at home.

Achieving that goal benefits both the client and the health-care system.

"It's an advantage for people to remain in their homes for as long as possible. Evidence shows that it leads to improved patient outcomes and improved quality of life," Siegers says. It's also less costly to the health-care system when clients are using emergency departments or acute care facilities only when it's appropriate.

"As Rapid Response nurses, we conduct assessments and care plans that help clients understand their disease process, how to manage their symptoms, why their medications are important, and when to ask for help. We can help connect them with appropriate resources and supports, and provide them and their caregivers with the information they need to manage common symptoms, such as shortness of breath and dizziness, without the need for them to access an emergency room or acute care facility."

Clients are referred to the program by hospital or community-based case co-ordinators.

"I have one client who has used the emergency room 11 times this year and another who visited the emergency room five times in the last four months," Siegers says. "In addition to the inconvenience and disruption, it can be very costly for them, since they don't always have coverage for emergency services such as ambulances and are paying out of pocket."

Frequent trips to an emergency room can often be avoided, she says, when the client is provided with the information and resources they need to manage their condition at home.

"Clients thrive when they have appropriate information and resources to manage their condition at home," Siegers says.  "Various 'what if' scenarios are meticulously described in the care plan to help ensure their safety, so they understand that to remain in their home they will need to monitor their symptoms and know when they have to seek additional medical support."

The program is a great example of the results that can be achieved when a good plan comes together.

"I absolutely love this new position and find it very rewarding," Siegers says.  "I've always enjoyed community-based health care and enjoy helping people maintain their independence in the communities in which they live  for as long as safely possible."

Her clients are big fans of the program too.

"When we've placed the proper supports in place, they feel very empowered," Siegers says.  "We'll notice that they are laughing more and there's an ease where, previously, they may have been having difficulties coping. People are most happy when they are at home and they are so appreciative of the services we provide."

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