Frailty Coordinator Lauren Jefferson supports seniors in their health care journey

Lauren Jefferson’s passion for her role as a frailty coordinator with Nova Scotia Health is evident when she shares how she is helping seniors to live healthier, fuller lives.

Atlantic Canada has the oldest population in the country and Nova Scotia Health’s Frailty and Eldercare Network (the Network) is taking steps to enhance how we support older adults in aging and living well, including introducing frailty coordinators across the province.

The frailty coordinator role is relatively new to health care in Nova Scotia. It was created to support network initiatives to optimize health care delivery through each phase of a patient’s interaction with the health care system.

Frailty is an age-related state of increased vulnerability which can increase over time as patients experience layers of health challenges. This can affect a person’s ability to participate in day-to-day activities and to live autonomously. Frailty can be prevented, and, in some cases, frailty can be improved or reversed.

Lauren is one of four frailty coordinators dedicated to each of the organization’s four zones. A primary focus of this role is to improve understanding, awareness and identification of frailty among frontline staff and physicians to enable them to provide better care to those that live with frailty.

An occupational therapist with experience in geriatrics and long-term care, Lauren began as a frailty coordinator in May, which made it possible for her to continue to help older adults on their journey to wellness. It also enabled Lauren and her husband, who were living in Halifax, to return to their roots on Nova Scotia’s South Shore where they grew up.

Now residing in Hebbs Cross, these high school sweethearts are parents to four-year-old Rowan and two-year-old Otis. Along with their Portuguese waterdog, Lewis, the family are very active, taking lots of walks along the abundant beaches and trails offered in this part of the province.

Research shows 83 per cent of older patients in hospital are not up and moving, spending just three per cent of their time upright and out of bed. This can lead to a decline in their physical health and mobility. Staying in bed is especially harmful for those who are experiencing frailty.

In June, Nova Scotia Health announced the introduction of the Early Mobilization Program to support continued efforts to improve health services for older adults. Under the province’s Action for Health strategy, 37 full-time mobility assistants are being hired across Nova Scotia to help eligible patients out of bed to walk up to three times a day. Evidence shows this simple daily movement means many patients can be discharged sooner.

The program targets older adults (65+) living with frailty and at the greatest risk of functional decline impacted by immobility. Patient risk is assessed using the Clinical Frailty Scale, which was developed by Dr. Ken Rockwood, QEII Health Sciences Centre internist-geriatrician and clinician scientist and medical director, Frailty and Elder Care Network. The goal is to identify patients within the first 24-48 hours of admission to hospital to offer support for purposeful mobilization.

“It is important that we mobilize patients as a routine part of the care we provide”, says Dr. Rockwood. “As we employ people who are specifically responsible to help patients move, we are physically coming along side patients and helping them get better.

On August 3, Nova Scotia Health’s Western Zone (South Shore, Southwest and Annapolis Valley) was the first zone to launch the Early Mobilization Program at its three regional hospitals - South Shore Regional in Bridgewater, Yarmouth Regional and Valley Regional in Kentville. Three mobility assistants are available at each site from 8 a.m. to 6 p.m., seven days a week to encourage patients to increase their physical activity.

Lauren provides leadership and ongoing support for the program in Western Zone. “As an occupational therapist, the most valuable part of the role for me is knowing that I have helped someone live a more fulfilling life,” says Jefferson. As of October 3, 182 patients have been referred to the program across the three regional hospitals.

Mobility assistants include recreation therapy associates and rehab assistants which are a vital part of a patient’s circle of care. They work collaboratively with the care team, freeing clinical staff to do other tasks. “The mobilization assistants are a gift”, says Gayathri Vijayachandran, RN, clinical practice lead, Acute Medical Unit at South Shore Regional. “In such a short time, they have become an integral part of our team. Patients love their walks with members of the mobility team, I have even heard them singing together in the hallway.”

Mobility assistants get to know patients and learn how to motivate them to move. This means knowing what is important to each person, whether it’s returning home or doing an activity that they enjoy. “We can see the change in the patients that are participating in this program”, says Vijayachandran. “When patients are more active, it speeds up their healing process. It is wonderful to witness this evolution, which has also improved staff morale.”

“We are hearing positive feedback from both patients and care providers”, says Jefferson. “For example, a patient recently stated that when the mobility assistant visits them it is the ‘best part of their day’. It is not only about the walk, but also about the social interaction. For me, this is why we do what we do”, says Jefferson.

Initial indicators show mobility assistants are positively impacting patients living with frailty to maintain their functional mobility and ability to return home following hospitalization. In addition to improved health outcomes and quality of life, earlier discharge from hospital also enables someone else to be admitted more quickly to hospital or long-term care. This is a win-win for both patients and the health system by improving patient flow and sustainability.

It is expected that the Early Mobilization Program will be available across the province in the coming months. Western Zone’s early start will benefit other zones as they can share lessons learned as part of on-going efforts to improve processes and approaches.