He is cared for by a group of health professionals that includes a family doctor, nurse practitioner, physician assistant and occupational therapist.
This article was published by The Toronto Star on August 6th 2012. To see this article and other related articles on The Toronto Star website, please click here
But Daniel is not in a hospital. He is in the living room of his East York apartment where he and his wife, Margaret, have lived for 42 years.
While other Ontario seniors in his position might find themselves in hospitals or long-term-care homes, Daniel can stay in his home, where he wants to be, because of a new program spearheaded by the Toronto-Central Community Care Access Centre, which co-ordinates local community health services.
The Integrated Client Care Program allows seniors at risk of hospitalization to stay in their own homes as long as possible with strong support from health-care professionals and community service providers.
Before connecting with the program last year, Daniel, a retired Canada Packers worker, hadn’t visited his family doctor in two years because he couldn’t get out of bed, let alone walk.
When he needed medical help during that time, Margaret was forced to dial 911, even if it was just for an ear infection or because his asthma was acting up. At a time when the province’s health system is under tremendous pressure with problems such as backlogged ERs, it certainly wasn’t the best use of health resources.
And it was hardly meeting the needs of Daniel, or Margaret, 81, his main caregiver.
Without any primary care, Daniel’s COPD flared up in January 2010 and he was hospitalized. In hospital, he contracted C. difficile, an antibiotic-resistant superbug that is particularly serious — potentially fatal — for the frail elderly. Contracting a superbug like this is one of the risks of being hospitalized.
It was after one of these trips to hospital that Daniel got hooked up with the Integrated Client Care Program. He had been discharged with instructions to visit his family doctor within a week.
“How was he going to visit his family doctor if he was completely paralyzed?” asks Dr. Tia Pham, director of the South East Toronto Family Health Team, across from Toronto East General.
So Pham, who works with the Integrated Client Care Program, became Daniel’s new family physician. She is among a group of health professionals from the family health team and CCAC that now visits Daniel at his home every month or two.
Through the program, Margaret can phone a physician assistant at the family health team any time she has concerns about Daniel’s health and, if necessary, extra home visits can be scheduled.
Stephanie Sanders, a care co-ordinator with the CCAC, visits clients like Daniel every six months to assess their changing needs. She hooks them up with community services such as Meals on Wheels, grocery shopping assistance, friendly visitors and transportation.
If clients have problems with their medication, Sanders can call in a CCAC pharmacist.
She even helped Daniel get a pressure-relief mattress when there were concerns about bed sores.
She has created an emergency transfer kit that she leaves in the Donilson house in the event Daniel has to go to hospital by ambulance. Upon calling 911, Margaret would give to paramedics the kit containing Daniel’s medical history, a list of his medications, name of his local hospital and phone number of the CCAC. Kits can also contain “advanced directives,” instructions to health professionals on end-of-life care. This could include, for example, a DNR, or “do not resuscitate” order.
The Integrated Client Care Program also provides help to the oft-overlooked caregiver. Through this, Sanders has been able to attend to some of Margaret’s needs.
Margaret is constantly at Daniel’s side and rarely gets out of the apartment. Sanders arranged for baseball tickets last season for Margaret, a big Jays fan, and for a respite worker to care for Daniel.
She made arrangements for someone to care for Daniel while Margaret attended Christmas festivities with relatives.
“I never get a chance to get together with them. I really enjoyed that,” Margaret says.
Sanders even arranged for a new pair of glasses for Margaret, something the pensioner hadn’t had in 10 years.
With a rapidly aging population and a $15-billion deficit, the provincial government wants to see more programs like this. The Liberals called for more home visits by doctors in the last election and they hiked spending for community health services by 4 per cent in the last provincial budget.
Meantime, Health Minister Deb Matthews has repeatedly said the reason she wants to freeze physician compensation at $11 billion is so she can increase funding to home care.
The Integrated Client Care Program also supports the province’s efforts to reform the primary care system, says Stacey Daub, CEO of the Toronto-Central Community Care Access Centre.
One of the big problems in primary care reform is the large number of “unattached” patients — those like Daniel who have high needs but no access to family physicians. Some observers say family doctors “cherry-pick” the healthiest patients because the fee-for-service system of paying doctors doesn’t provide sufficient incentives for them to see the sickest.
“One of the reasons physicians don’t take on complex clients is because they don’t have the appropriate supports,” Daub says.
“Our partnership with primary care has enabled us to leverage one another’s competencies — medical care and community care — to create a supportive wrap-around care for the most vulnerable and complex populations,” she adds.
The program started as a pilot project but is now fully operational, with plans to expand it to also serve palliative, medically fragile and technology-dependant clients.
But its success can best be measured through the experience of clients.
Says Sanders of Daniel: “It has been a good year. He hasn’t been to the hospital at all this year.