Health authority pleads with nursing homes to help lessen ER overload

A top executive at the Nova Scotia Health Authority met with up to 20 nursing home administrators from the Halifax area last week to ask them to do more to help reduce slow ambulance offload times and emergency department overcrowding. 

Tim Guest followed up that meeting with a memo to all 136 long-term care facilities and 30 home-care agencies in the province. He listed five ways to help ease the overcrowding that has led to the long wait times.

The list includes:

• Calling local emergency departments before sending residents to hospital.
• Working to limit the number of times they refuse to accept a resident back after a hospital stay.
• Closing their facilities because of flu only when "warranted." 

Guest ended that list with a warning: "Residents sent to hospital who do not have emergency or acute-care needs will be transferred back to their home facility."

The authority does not track the number of nursing home patients arriving in emergency departments who don't require urgent care. It does note the number of people waiting for discharge to a nursing home.

"On November 14, 2018 there [were] 316 people waiting in hospital," said the health authority in an email. "This was [the] highest number of people waiting in hospital for long term care placement since before April 2014." 

'It's not a frivolous thing'

Home-care companies were provided with their own five-point list, which included the same advice about transfers to hospital and refusal of service, but did not include the same warning.

Every year, hundreds of nursing home residents are sent to hospital for care.

According to figures supplied by health authority, that number has fluctuated in recent years from 1,506 admissions in 2015-16, to 1,354 in 2016-17 and 1,510 in 2017-18.

James Balcom, chief financial officer at GEM Health Care Group, which is the second-largest nursing home provider in Nova Scotia, dismissed the suggestion any of his facilities were sending residents to hospital without good reason.

"It's not a frivolous thing," he said.

Bobbi Rose, director of health care services at GEM echoed that sentiment.

"We are doing our due diligence on our end to ensure that that doesn't happen," she said. "We do know the crunch that that they have in the current acute-care setting and we don't want to overload that.

"But … if we have a client who absolutely needs that access to services, we have to do our due diligence, as professionals, to ensure the safety and the quality care for that client and send them out." 

Refusing to accept residents back

In 2015, 51 patients were not allowed to return to nursing homes after they were discharged from hospitals. It climbed to 100 the following year.

The authority did not provide figures for 2017, offering this statement instead.

"January 1, 2017 and May 14, 2018, 35% were due to concerns about behaviours, 22% were about safety concerns, 12% were due to the facility indicating it could not safely provide care.

"Other reasons for refusals include inadequate staffing, lack of private rooms, security and lack of one-to-one attendant care," said an email from the NSHA.

Balcom said refusals did happen at GEM homes, but that the delays were often the result of "incomplete" patient files or patients who weren't "medically, physically or emotionally" stable enough to return to the facility.

Rose agreed.

"Sometimes these delays are necessary delays so, for example, we need to ensure there's appropriate discharge planning to decrease the chance of readmission to hospital," she said.

Better patient care co-ordination

Madonna MacDonald, senior director of acute medicine services at the health authority, said the key to solving the problem of slow patient flow is better communication between institutions.

"By co-ordinating care and having conversation, then there might be a better opportunity to manage that condition without having to have the visit in emerg," said MacDonald.

"In good faith, people are arranging care and coming to the emergency services because they feel that that's the best place," she said. "Sometimes it's not.

"What we're trying to do is to create an awareness that emergency services are really busy and that there may be a better way to manage some cases by connecting, by planning the care together between community and consult services." 

Adding nursing home beds 

Balcom said he had written Health Minister Randy Delorey suggesting three ways to improve things, including

• Converting beds currently empty in residential care facilities to nursing home beds.
• Doing a trial in which patients could be returned to facilities closed due to a flu outbreak.
• Adding more nursing home beds to existing facilities.

Of the almost 7,000 nursing home beds in the province, 31 are empty despite wait lists that extend from eight people in Cumberland County to 467 people in the Halifax-area.

Wait times in the province span from 59 days at Milford Haven in Guysborough to 548 days at Harbourstone Enhanced Care in Sydney. 

According to the health authority, there are a variety of reasons why some beds are empty.

"One facility has 5 beds closed due to renovations," says an email from spokesperson Carla Adams. "Another facility has 2 beds closed due to flu outbreak."

Balcom says as many as 30 beds are "perpetually empty" at his company's residential care homes.