Every time I encounter our health care system from the patient’s perspective I am blown away by how disjointed and difficult to navigate it is. Again this week I was working with an elderly man in Mississauga who was discharged home from the hospital after a 14 day stay. This man has stage 4 colon cancer but was managing very well- still golfing a few times a week- until his condition required hospitalization. He was well enough to go home again, however his COPD now required him to be on oxygen 24 hours a day.
Leading up to his discharge I started the process of what I do best: navigating our health care system. On the day he was supposed to go home, nobody knew that was the plan until I spoke to the bedside nurse that morning and she reported that yes, the discharge orders were completed and the patient will be going home with oxygen. OK….
It’s funny because I had spoken to the charge nurse on the floor the day before, and had left a message for the discharge planner who didn’t call me back, and nobody that I spoke to seemed to know what was going on, until all of the sudden he was ready to go home. As is the unfortunate reality, the proclamation of “you can go home now” leads to a flurry of activity for the family about what to do now. Since I’m not new to this game, we were ready for it and the PSW accompanied his wife to the hospital to pick him up. They sent him home with a portable oxygen tank and a phone number to call when he got home. All of the onus to arrange the home oxygen was on the patient. Being sent home on oxygen can feel scary and overwhelming, just a phone number and a good luck seemed inadequate.
Then there is the CCAC, an entirely separate entity that the hospital says “will call you”- you better hope you don’t fall through that crack. There are two different CCAC offices to work with, one for the hospital, and one in the community. Then there are one, two, or more agencies involved based on the services being provided. One agency sends the nurse and occupational therapist, and the other agency sends a personal support worker, and then there’s the private home care services, oh and it’s an entirely different company that does the oxygen. The continuity of care goes out the window since no one seems to be talking to each other. I had to leave three messages for the CCAC care coordinator before I got a call back to determine the services being provided and by whom so that I could connect with the other nurse and collaborate on the client’s plan of care.
Meanwhile, the client’s status has deteriorated and additional support is required. The client had no idea who to ask for help within the public system. I called the family doctor who hadn’t been updated on the community care plan or the client’s status. He was helpful and offered to make a house call in the next few days, I then had to review multiple medication questions and discrepancies. I then spoke to the community pharmacist to close the loop on the medications and she agreed to create a blister back of the medications to prevent errors. I like to describe blister packs as similar to the advent calendars you see at Christmas with the chocolates that you pop out. With a blister pack your medications are conveniently arranged for you by the day of the week and the time of day, and you always know if you have taken them.
I started this company because of the significant gaps in our health care system and the obvious need for people to receive comprehensive home care services in one place, but every time I start the process with another client I am always hoping that this time our system will be better, this time the gaps will be smaller, this time I’ll be providing just the ‘nice to haves’ and our public health care system will manage the ‘need to haves’….yet every time I experience the opposite.
I’m going to keep hoping for change, and work on bridging the gaps in home care services…..one client at a time.
-Jennifer Kazmaier RN