Integration of Nurse Practitioners into the Rehabilitation and Reablement (R&R) Care Team for Vulnerable Seniors

About the project

The New Brunswick Extra-Mural Program (EMP) offers a service called Rehabilitation and Reablement (R&R). This in-home service provides vulnerable seniors with intensive, short-term care after a hospital admission or health issue. The goal is to restore their independence so they can remain at home. When an R&R patient has an urgent health issue, their medical needs are not always met promptly in the 
community. As a result, they often end up in the emergency room or readmitted to the hospital. This can strain both the healthcare system and the patient. To address this, EMP added a Nurse Practitioner (NP) to the interdisciplinary health care team in 2022. The NP supports R&R care providers in meeting R&R patient needs outside the hospital.

This project assessed if the new NP-R&R care model:

  • helped EMP staff feel more confident and supported in their roles, and/or
  • increased other care providers' confidence in referring patients to R&R.

Conclusions and lessons learned

  • The NP-R&R care model could help address New Brunswick health care system challenges and allow more seniors to age in place.
  • The NP performed tasks that could impact whether a patient remains at home, such as:
    • providing medical advice and direction on patient cases,
    • liaising with primary care providers and specialists,
    • ordering and interpreting medical tests,
    • serving as a temporary PCP for patients without one in the community, and more
  • EMP staff felt that having an NP as part of the interdisciplinary team could improve the quality and effectiveness of EMP-provided community-based care. Providing care that diverts patients from emergency rooms has the potential to enhance the efficiency of the province’s health care system.

Recommendations

  • Hire additional Nurse Practitioners and expand their services to all EMP patients to enhance clinical support.
  • Improve internal (e.g., EMP interdisciplinary team) and external (e.g., PCPs, non-EMP care providers)communication about the NP role and scope of practice.
  • Pilot strategies to address the limited availability of experienced home support staff.

To learn more read the complete project findings (PDF 178 KB)