Integrating Acute and Long-Term Care through a Nurse-Led Outreach Model: Advancing Staff Capacity and System Collaboration, Toronto, Ontario, Canada

Background: Long-term care (LTC) residents are a vulnerable population facing high risks due to frailty, complex medical conditions, and cognitive decline—factors that lead to frequent Emergency Department (ED) visits and hospitalizations, with one-third deemed avoidable. Chronic staffing and training gaps in Ontario LTC homes have intensified these issues, while the COVID-19 pandemic underscored the need for accessible, specialized care closer to home.

 

The 2022 INTERCARE study demonstrated that nurse-led models and digital tools can reduce hospital transfers¹. In response, Humber River Health (HRH) leveraged targeted funding to expand its Nurse-Led Outreach Team (NLOT), a mobile emergency nursing service supporting affiliated LTC homes, to deliver outcomes aligned with the Quintuple Aim and strengthen staff capacity for timely, appropriate in-home care.

 

Approach: Following Ministry of Health funding in May 2023, HRH expanded its established NLOT from four to seven team members, including six nurse practitioners and one nurse clinician to support 11 LTC homes within HRH’s catchment, operating 10 hours/day, seven days a week. NLOT aims to prevent avoidable transfers and enable seamless discharges for hospitalized LTC residents. Services include in-hospital assessments to facilitate repatriation, rapid in-home clinical evaluations, interventions, clinical training and capacity building (e.g., IV therapy), and connections to specialty services.

 

In December 2023, Ontario Health at Home, the main provider of IV therapy in LTCs, announced it would discontinue this service effective January 1, 2025, transferring responsibility to LTC staff. NLOT proactively engaged its community of practice, composed of leaders and clinical champions across 11 LTC homes, to collaboratively plan and implement this change. In response to growing post-discharge IV therapy needs (ranging from two days to six-plus weeks), NLOT trained over 250 registered nurses using a model of demonstration, performing with guidance, and then teaching it to someone else. Training included didactic sessions, simulation-based practice, and just-in-time support for real-life scenarios. Initial focus on the added nursing skill of peripheral IV initiation, care, and maintenance, expanded to central venous access devices. The approach fostered LTC registered staff confidence, competence, and readiness, while respecting scopes of practice. This initiative supported safe transitions, reduced acute care bed days, and strengthened collaboration between acute and LTC sectors.

 

Results: One year post expansion, NLOT demonstrated increased LTC staff knowledge and capacity in IV care; improved resident and caregiver, as well as LTC staff experience; equitable access for over 2,200 LTC residents; fewer ED visits and hospitalizations; and acute care bed savings through earlier discharges. These outcomes validate NLOT’s impact in building LTC workforce capacity and advancing care closer to home.

 

Implications: This presentation will outline the NLOT model, share results and lessons learned, and explore future directions for scaling and sustaining nurse-led outreach programs. Findings will inform system-wide strategies to strengthen LTC capacity and address health human resource challenges—ensuring equitable, timely, high-quality care for vulnerable residents closer to home.

 

References: 1. Kaehr EW, Unroe KT. Complex problems need comprehensive solutions: The INTERCARE model provides evidence for nurse-led nursing home care models. J Am Geriatr Soc [Internet]. 2022;70(5):1365–7. Available from: http://dx.doi.org/10.1111/jgs.17749.