Enhanced Community Pathway

During a health or social crisis, seniors who lack easy access to primary healthcare and social supports often resort to already-strained emergency departments (EDs) to receive care. However, seniors in the ED do not always receive the care that best addresses their needs. Rapid assessment of seniors’ health needs, followed by timely navigation to services that combine health and social supports, may better meet the needs of seniors at risk of hospital admission. This program introduced a rapid access pathway to short-term supports for seniors who had recently experienced a crisis caused by an urgent health and/or social issue. Known as the Enhanced Community Pathway (ECP), the program referred eligible patients to a joint Social Development (SD) and New Brunswick Extra-Mural Program (EMP) team, who assessed the patient within 24 to 48 hours of the referral. Based on the assessment, the SD/EMP team developed a care plan that outlined recommended health and social supports for the patient. The care plan was implemented within 48 to 72 hours of the referral in collaboration with a group of healthcare professionals known as the Care Team. Patients could access ECP supports free of charge for up to 30 days. The goal of the program was to reduce ED utilization and rates of hospitalization for at-risk seniors, helping them remain in their homes and communities.

• Findings suggest that rapid integrated assessment and provision of short-term supports through the ECP helped seniors in crisis avoid ED admission and remain in their homes. However, more research is needed to assess the program’s impact on hospitalization rates. While the data revealed an increase in hospitalization rates following patients’ ECP discharge, the project was unable to assess the effects of other factors such as seasonality and co-existing health conditions.
• Lack of program awareness among current and potential referral sources may have resulted in a lower number of referrals than originally anticipated alongside a higher number of inappropriate referrals.
• Internal processes and lack of immediate availability of external agencies and service providers contributed to delays in the initiation of short-term supports following timely initial assessments.

• Draw on lessons learned to integrate the ECP into regular SD/EMP practice.
• Promote program awareness among current referral sources while broadening the range of new referral sources.
• Before instituting a province-wide rollout of the program, consider and plan for regional variations in the availability of short-term supports and community resources.

To learn more read the complete project findings (PDF 147 KB)

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