Improving care for seniors

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By Roxanne Torbiak

Despite having Chronic Obstructive Pulmonary Disorder (COPD) and Congestive Heart Failure (CHF), 89 year old Frederick Kendall enjoys a very active life. Regular activities include riding his bicycle around town, lawn or carpet bowling three times a week, gardening and tending to his tomatoes, volunteering in his community and travelling.

In Spring of 2016, the Beamsville resident was eagerly awaiting a special ‘bucket list’ trip he had planned to Iceland with his son and grandchildren.Unfortunately, Mr. Kendall suffered a setback when his heart failure worsened and his trip was at risk of being cancelled.

As a result of long standing health issues, Mr. Kendall has had hospital stays at two sites of Hamilton Health Sciences – West Lincoln Memorial Hospital (WLMH) and Hamilton General Hospital sites. He credits the great health care teams at both hospitals for helping him return to health every time.

In the past, he would return home and resume his regular lifestyle when he was ready. But this time was different; after a two-week stay in WLMH hospital, the previously vivacious senior felt fearful and lacked confidence.

Mr. Kendall was identified as a candidate for two programs offered out of WLMH which aim to improve care for seniors and others with complex conditions — Integrated Comprehensive Care (ICC) and Health Links, which are initiatives of the Ontario Ministry of Health and Long-Term Care and the Hamilton Niagara Haldimand Brant Local Health Integration Network. Hamilton Health Sciences is the designated lead hospital for the Hamilton West Health Link and the Niagara North West Health Link.

These customized programs link the patient and family with providers including primary care, specialists, hospitals, long-term care, home care and community supports services such as Meals on Wheels. Together, they a develop care plan that is focused on what is important to the patient.

“For people living with complex health care needs, transitioning out of hospital can be complicated because there are many providers involved,” said Tara Bloomfield, a registered nurse and care coordinator for ICC and Hamilton Health Sciences’ Health Link. “Effective communication and information sharing among the entire team is key to providing our patients with the care they need, when and where they need it.”

Upon making the move home from WLMH, the teams focused on teaching Mr. Kendall self-management skills including how to recognize worsening symptoms to help him manage his chronic illnesses at home. Mr. Kendall received visits from a physiotherapist, an occupational therapist, a dietitian, a personal support worker and his family doctor, with Tara Bloomfield acting as his nurse and care coordinator. Working collaboratively, the team helped to ensure that  Mr. Kendall could follow his care plan safely in his home to achieve his goals.  If concerns arise, the appropriate team member works to support Mr. Kendall to avoid an unnecessary trip to the emergency department (ED). However, should there be need for a visit to the ED, Mr. Kendall’s care plan is available so that staff and physicians have the information they require.

“The ICC and Health Links teams boosted my morale and my ambitions,’ said Mr. Kendall. “They made it possible to love life again.”

As a result of this comprehensive support, Mr. Kendall soon resumed almost all of the activities he loved prior to his health event, except he recently needed to give up his cycling.

“The hill on the way to my house became too hard for me. So, I donated my bike to a farm for a migrant worker, and got an electric bike instead.”

This inspiring 89 year old man didn’t stop there … he also set his sights on fulfilling his bucket list trip to Iceland.

“I’m a firm believer that if you want to do something, you’ve just got to do it.”

Dr. Santino DePetrillo, Mr. Kendall’s family physician and Bloomfield worked together to prepare him for a safe journey. They created a care plan that included bringing a blister pack of pre-sorted medications and educating him on their use if he experiences symptoms of a flare up while away.

Mr. Kendall had a wonderful trip and enjoyed Iceland’s clean fresh air, ‘never coughing once.’

Since visiting Iceland, Mr. Kendall has already crossed another trip off his bucket list. In November, he visited the polar bear capital of the world, Churchill, Manitoba.

“Without this coordination, travel would be impossible for me. This team has saved my life. ”

What’s next on Frederick Kendall’s bucket list? A trip to the Arctic Circle for his 90th birthday.

Roxanne Torbiak is a freelance writer, specializing in healthcare communications.