Transitions in Care

A new program engages medical professionals, people living with dementia, family members and care providers to reduce unnecessary emergency department visits

Wayne and Judy Hykaway began living with dementia in 2016 when Judy was diagnosed with age-related short-term memory loss and later with dementia. As Judy’s condition progressed, the couple, who have been married for 47 years, sold their home and moved into independent living in Calgary’s AgeCare Midnapore community.

In 2018, as Judy’s condition worsened, the decision was made to move her into long-term care at AgeCare SkyPointe in northeast Calgary to be closer to their daughters. Wayne moved into supported living on the same floor.

“I promised Judy that I would be with her each morning and stay until she fell asleep each night,” says Wayne. “Our two daughters live nearby and come to visit often.”

In July 2019, Judy was admitted to the emergency department (ED) as she was having difficulty breathing. With its overhead pages, bright lighting and lack of privacy, the ED can be anxiety-inducing, especially for someone living with dementia. Although Wayne says the treatment Judy received there was excellent, it was still a stressful experience for the entire family.

“My daughter spent the first night with Judy. There was so much noise and chaos that neither slept,” says Wayne. “And, when I showed up in the morning, they were both in a panic.”

Judy’s tests returned few results except that she had perhaps aspirated some food and had mild pneumonia. The doctor suggested Judy be admitted for seven day’s observation, which seemed too long to Wayne.

“All I could think was, ‘They can’t spend another night,’” he says.

Wayne wasn’t alone in his concerns. Inpatient admissions are linked to an increased risk of infections, falls, delirium and functional decline. This is bad for patients and their families and can prove costly — a reduction in unnecessary transfers could save the province $7.44 million annually.

Thankfully, a new program is exploring how to address the issue. Alberta Health Services’ (AHS) Transitions in Care project, which was launched in April 2019 and is scheduled to run until June 2022, educates health-care professionals, caregivers and family members about available options so that the person living in long-term care can be assessed and potentially treated at home rather than transferred to ED.

“Across Alberta [approximately] 28 residents are transferred from long-term care to emergency departments daily — that’s over 10,000 residents a year,” says Shawna Reid, a masters prepared registered nurse and a senior practice consultant with the Emergency Strategic Clinical Network, which is one of the Transitions in Care project’s main partners. “Many to most of those will end up being triaged as less urgent or not urgent. Our primary outcome is a reduction in transfers from long-term care to emergency departments.”

Transitions in Care, which was made possible thanks to a Partnership for Research and Innovation in the Health System grant (PRIHS), opens up communication among health-care providers in different departments, specifically between those in long-term care and emergency physicians. It also teaches caregivers, nurses and health-care staff to watch for very subtle changes in behaviours, body language, eating habits and so on, to catch health issues before they can progress. This information then helps inform the best patient-centred approach, whether that is to call a doctor, the AHS call centre RAAPID (Referral, Access, Advice, Placement, Information & Destination), the Community Paramedics (Mobile Integrated Healthcare), or, only if appropriate, transport the resident to the ED.

Wayne is already a member of the Resident and Family Council at AgeCare SkyPointe, a group that addresses quality of life concerns and enhancements for those living within the AgeCare community. When he heard about the Transitions in Care project in April, he applied to be part of it and was selected to share his insights and experiences. When Judy was admitted to the hospital three months later, Wayne’s experience with the initiative helped him feel empowered to share his concerns with the emergency doctor. He felt it would be better to take Judy home, where she could be observed with familiar people caring for her. The doctor agreed and commended Wayne for advocating for his wife.

Today, Wayne is a member of many programs and projects across Canada, where he continues to share his experiences and insights.

“I get involved in these projects because I’m hoping to find people who can share advice about what has worked for them,” he says “And, if I am going to spend time away from Judy, then I want to pay it forward doing something worthwhile and meaningful that will benefit not only my family but other families as well.” [ ]