Nurse-Led Outreach Team helps resident receive complex treatment closer to home
Access to specialized care can be challenging for older adults living in long-term care homes. A recent success story from a Nurse-Led Outreach Team (NLOT) based at Humber Regional Health demonstrates how innovative partnerships can bring advanced care directly to residents and reduce avoidable hospital use.
A resident living with severe iron deficiency anemia had experienced seven emergency department visits and two hospital admissions in a single year while undergoing ongoing diagnostic investigations. Following a detailed review, the NLOT identified signs suggesting the condition was more complex than initially understood and coordinated further assessment through specialist consultation and a bone marrow biopsy.
The investigation led to a diagnosis of Myelodysplastic Syndrome alongside severe iron deficiency anemia. Working with specialists, the NLOT coordinated iron infusion therapy, first in hospital and then directly within the resident’s long-term care home.
The impact was significant. The resident reported improved energy levels, better cognition, increased participation in everyday activities, and fewer symptoms related to anemia. Most importantly, there were no hospitalizations following implementation of the new treatment approach. The initiative also reduced transportation costs and the burden associated with repeated hospital visits.
This example highlights how specialized outreach services can improve health outcomes while allowing residents to remain in the comfort and familiarity of their long-term care home.