Most seniors prefer to live at home, autonomous, active, and independent, surrounded by family and friends. To age well in place, Canadian seniors require community-based health services provided by integrated, interdisciplinary health teams. The reality is that aging in Canada today is synonymous with living with multiple chronic illnesses, and health decline is often not gradual but punctuated by episodic medical events, with each event carrying the risk of hospitalization and even death. As nurses, we see the sad and sometimes devastating results of needless or lingering hospitalizations for seniors. Such hospitalizations can be avoided when interdisciplinary community-based health teams work together in innovative ways. Seniors stay in their homes, not in hospital hallways.
One such successful initiative in B.C., the nurse Debbie model, does exactly this. Family physicians, nurse practitioners, and home care nurses work together to identify frail elderly individuals and care for them in their homes. In the year of its inception, 2015, the annual salary of one RN avoided 260 emergency room visits and over 8,000 hospital days. Now, two years later, local B.C. health authorities have hired 18 other nurse Debbies to build and strengthen this initiative. Its success lies with the expert home care nurses connected with frail elderly Canadians in their homes, who then collaborate with their family physicians or nurse practitioners. Imagine the upstream and cost-saving benefits from initiatives such as these.