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CHEO has launched a program that helps families after their child has been discharged from hospital to provide follow-up care and support during the transition back to home.
The Inpatient Medicine Discharge Program is delivered by CHEO’s Home and Community Care Rapid Response Nurses, a dedicated team of six nurses and one nurse practitioner.
Nurses call families within one to two days of discharge to review discharge instructions and guide caregivers, helping them through “caregiver anxiety,” a common after-effect of a child’s hospital visit.
Nurses also decide whether an at-home follow-up visit is necessary, whether the child needs to see a primary care provider, or if they need to return to hospital.
The program is part of CHEO’s commitment to bring care closer to home for children, youth and families in the region and improve access to care, especially in rural areas and for newcomers to Canada.
Sylvia Quinn was thankful for the program last fall.
She had to take her daughter Haisley to CHEO in the middle of the night, driving 40 minutes from their home in Metcalfe, which is located in Ottawa’s rural south end.
Haisley, not yet two, was coughing, had trouble breathing, and spiked a fever. She was assessed in the Emergency Department and diagnosed with a severe case of croup, an infection that causes swelling in the upper part of the airway in the neck. Symptoms also include a barking cough.
Haisley was admitted to CHEO so medical staff could monitor her breathing and oxygen levels, and she was discharged the following evening.
Two days later, Haisley continued to have coughing fits, still had trouble breathing at times, and she battled an on-again, off-again fever. Her parents were unsure what to do.
That’s when they received a call from rapid response nurse Jodi Ouellette. After some discussion, Ouellette made the clinical decision to drive to the family’s home to check on Haisley in person.
Ouellette reassured them Haisley’s lungs were clear, her fever was gone, and her condition was improving. The visit saved them another potential 40-minute trip to CHEO.
“It’s a game changer. This is such a good idea, and such a good program,” said Quinn.
“I cannot say anything but amazing things about our experience and the care they provided for our daughter.”
The program is part of a teaching discharge model that helps inform families about caregiving needs, which can sometimes include complex health-care equipment such as feeding tubes.
Madelaine McFadden, who heads CHEO's rapid response nursing program, said families often aren’t able to fully take in discharge instructions when leaving the hospital — whether due to fatigue, stress or other distractions.
She said nurses have called, on average, about 50 to 60 families per week since the program launched as a pilot in September. It has since expanded to help more children, youth and families.
The program has also caught cases where a child should return to hospital based on a nurse's assessment of their condition. In this case, nurses can also help streamline the readmission process, improving the experience for families and lessening work for the Emergency Department.
The Inpatient Medicine Discharge Program also exemplifies CHEO’s commitment to integrated care in the region, building relationships with health-care services and programs in rural communities, including well-baby drop-ins, to help families who don’t have a primary care provider.