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Bringing patients home

Richmond Hospital has a new team that is helping to bridge the gap between hospital visits and health care in the community.
Tatjana Orcic and three other home care nurses are now employed as Community Liaisons (CLs) at Richmond Hospital. The new CLs came on-board to work closely with medical, surgical, palliative and intensive care teams at Richmond Hospital.
Their job? Get patients from hospitals and back into their own homes safely with appropriate levels of home care and support.
“The benefit of our community expertise is that if someone is admitted to hospital and is already known to home health, I can access patient information and care plans from community and share it with acute quickly,” Tatjana says. “This means patients receive the care they need in a timely fashion. CLs also help identify appropriate community resources to enable timely discharge for patients. The longer a patient stays in hospital, the greater the risk for deconditioning and hospital acquired infections. We want to decrease unnecessary length of stays.”

A made-in-Richmond approach

Community Liaisons are unique to Richmond. “They’re part of the home health community and they’re experienced home care nurses. That background is a big advantage,” says Jan Mathewson, coordinator of the Richmond Care Transitions team.
“If the patient is known to community and we’re already providing services to that patient, we can bring information related to what their home situation is, what their family situation is, when they come into hospital. This way, we don’t have to recreate their story because our CLs know these people.”

Familiarity leads to improved care

The ultimate goal of the new CL team is to improve care. CLs return patients to the comfort of their own homes quickly and safely. By doing so, length of stay is reduced. By supporting patients well in community, readmission rates can be reduced as well.
Tatjana says her familiarity with patients makes a big difference in not only the quality of care, but also to the patient’s comfort level.
“It’s great because I’m seeing patients in the hospital who I knew in community for so many years,” she says. “For them, we’re a familiar face, somebody they know and we’re a connecting link. I think it’s comforting for patients.”
SOURCE: Bringing patients home ( )
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