CARP Sudbury will take Part in new Seniors’ All-Inclusive Care Program

“My Home, not a Nursing Home” were demands made by many families in California back in the 1980s who were lobbying for better home care for their older family members.  They wanted them to stay in their home rather than have to go into a nursing home.  As a result of this movement, a program called PACE  ( Program of All-Inclusive Care of the Elderly ) was established.  Programs are now available throughout most states in the USA and in some Canadian cities.  Patricia (Pat) A. Douglas, Chair Sudbury CARP Chapter is pleased to announce that Greater Sudbury will have a PACE program in operation by April or soon after.

The Sudbury Chapter had been advocating for such a program in the City of Greater Sudbury since 2011.  Sudbury with its high population of older seniors requiring hospital care looked to the PACE program as a  means to prevent their illnesses from exacerbating and their immediate need for nursing home placement  shortly after being discharged from the hospital.  PACE would alleviate this problem by keeping these seniors in their homes longer and perhaps never requiring nursing home care.

What is PACE?   PACE will offer comprehensive long term services and supports to frail elderly over the age of 65 years at risk for nursing home placement. In Sudbury, the program will enroll those individuals who are frail, incapacitated and with multiple health problems, i.e. diabetes, hypertension and vascular disease, who have recently been discharged from the hospital, Health Science North, and without a primary care provider.

Transportation will be provided to a “PACE Centre”, in this case, a former hospital site, 2 to 3 times per week.   This Centre will be staffed by a PACE team comprised of a physician, social worker, physiotherapist, speech language pathologist, nurse, occupational therapist and reactivation worker support.  Health Sciences North (HSN) will utilize existing personnel.  HSN has secured funds to operate this Centre for one year. The Sudbury Chapter will play a role in lobbying all levels of government for funds so that the Centre will be able to operate beyond a year.  Pat Douglas has volunteered to assist the Planning Committee.

At the Centre, care planning will be done with the “member” (patient), his or her care team, and appropriate family members.  In Sudbury the Treatment Plan will be individualized and based on 12 common geriatric protocols: advance care planning, health maintenance, medication management, difficulty walking/falls, chronic pain, urinary incontinence, depression, hearing loss, visual impairment, malnutrition or weight loss, dementia and caregiver burden.

Because the members will attend about 2 days per week, staff will get to know the patient extremely well- their concerns, their moods and their condition. This means that the staff will quickly determine when a member does not seem him/ herself on any given day.  In that case, he/she would be sent to see the nurse or the physician, where the clinician could intervene quickly to prevent exacerbation of the problem; thus preventing or delaying the readmission to the hospital or need for long term care.

While at the Centre, members will be involved in activities to maintain their mental and physical health.  As well, a nutritious snack is usually provided.  Socially they will be able to interact with other seniors which is vitally important, because most members live on their own which often leads to loneliness and depression.

Every patient who remains in the community instead of a long-term care home could save the system up to $50,000 per year.  For cash strapped provincial governments, the aging population is a concern because older adults account for a huge proportion of health costs in Canada.  In 2008, people  85 and older consumed  $21,000 of health-care spending per capita.

Edmonton operates a similar program called CHOICE which has been remarkably successful in keeping the frail elderly out of hospital. According to a one year study done by the Alberta government, admission to the PACE program reduced emergency visits by 30%  Obviously CHOICE was effective in keeping the elderly healthy and delaying their admission into long-term homes.

Sudbury is hoping for similar results to those obtained by the PACE program.


Respectfully submitted by,

Patricia (Pat) A. Douglas, Chair

Sudbury and area Chapter of CARP #09