Bringing Continuing Care into Primary Care: How a new role is improving access and support for patients

Wendy Wierstra couldn’t be a better fit for her new role as a care co-ordinator at Woodlawn Medical Clinic in Dartmouth.

For more than 20 years, Wendy has worked as a care co-ordinator with Nova Scotia Health Continuing Care. But last fall, she took those skills and decades of experience and became a bridge between Nova Scotia Health Continuing Care and primary healthcare.

The new role is already making a noticeable difference for patients, families, and healthcare providers. Across the province, we currently have 15 care co-ordinators supporting 20 clinics.

The goal of the initiative is simple: help people connect with Continuing Care services earlier and more easily.

“There were lots of people showing up to the hospital and needing long-term care who had never accessed continuing care,” Wendy says. “This was an effort to help people access services earlier so they can remain at home longer.”

Making support more accessible and familiar

In her role at the clinic, Wendy provides education, consultation and direct support to patients who may benefit from continuing care, whether they’re ready for services now or still weighing their options.

“What I’m finding is that when I do consults with people, it allows me to become more familiar to them and their physician or nurse practitioner,” she says. “When home care is suggested to a patient, the physician or nurse practitioner is suggesting they speak with me as opposed to calling a 1-800 number.”

This familiarity helps patients feel more comfortable taking the next step. It also gives providers a clear and consistent point of contact.

“When a physician or nurse practitioner makes the referral with confidence, it transfers that confidence to the patient,” she says.

Closing the loop

One of the biggest challenges in the past was follow-up. Referrals were often sent to Nova Scotia Health Continuing Care without providers knowing what happened next with the patient. Wendy’s presence in the clinic changes that.

“I always loop back and let them know if the person opened a file or not, and where it stands,” she says. “It’s really just closing the circle and making things more efficient.”

Wendy is able to respond quickly to urgent or complex situations. She recalls helping a woman in her mid-90s who suffered a compression fracture and suddenly needed support at the place she calls home.

“The physician sent me a request and asked if I could connect with the family,” she says. “I was able to get out that day and put service in place the following day. It really allowed the family to step back a bit and rest, and it helped facilitate her healing.”

Supporting providers and easing pressure

Wendy also supports physicians, nurse practitioners and clinic staff by answering questions, sharing relevant program information, and helping them understand the support available to patients.

“They drop by my office with quick questions about things they may not have sought out before,” she says. “Because I’m here and available, it’s easier for them to ask.”

This collaboration supports more co-ordinated care.

Helping people at the right time

For Wendy, the value of this role comes down to making services easier to navigate.

“It takes away the mystery of continuing care,” she says. “People can book an appointment with me or walk down the hall if their provider thinks it would be helpful. I can spend 40 to 45 minutes with someone, and that’s time physicians and nurse practitioners aren’t always able to spend.”

Some patients see Wendy once and return months later, once they feel ready. “They’re more comfortable because they know they’re just going to have another conversation with me. They’ve already met me.

“Everything we do is built on relationships, and that’s really the key,” she says. “Continued collaboration will ensure people are receiving the right support at the right time.”

She believes the model is helping the system move in the right direction.

“We need to connect Nova Scotians with the services they need. That means making it easy for people to connect with us and find us when they need us. You don’t know what you need until it’s time, and that’s when you have to connect with someone who is an expert. This is the way to go.”

If you or someone you know needs help to stay at home, Nova Scotia Health Continuing Care can help. Call 1-800-225-7225 or visit nshealth.ca/continuing-care.  
 
For more information about Health Homes, visit https://www.nshealth.ca/health-homes. 
 

Photo of Wendy Wierstra.