St. Joe’s clinic strives to help the community’s “orphan” seniors

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There are thousands of seniors living in the diverse communities surrounding St. Joseph’s Health Centre, and each year the number of seniors we care for continues to rise. Many live near family or have a strong social network to help them cope with the health issues that come with aging. Many others are all alone.

Dr. David Tal, Chief of Geriatric Services at St. Joe’s, refers to this group of patients as “orphan” seniors, and they account for a large number of patients we see at St. Joe’s.

“We have a lot of orphan patients – patients who have either never had a support structure, or have outlived a support structure,” explains Dr. Tal.

The Elderly Community Health Services (ECHS) clinic at St. Joe’s works closely with these patients to make sure they can be connected to the support they need that is critical for them to lead a healthy life in their homes.

They’re often referred to the clinic from St. Joe’s Emergency Department and other outpatient clinics, or from outside sources like family physicians or concerned neighbours. Many do not have a family doctor, while others lack family nearby to take them for check-ups.

“Friends die, children move away, and they’re isolated,” says Rosemary Fine, the Nurse Clinician in the ECHS clinic at St. Joe’s.

Fine often gets calls from community members telling her a local senior needs help. One day they’re bringing in meals or shoveling their driveway – then over time, neighbours notice they’re not out and about anymore. They might not have caregivers, or even visitors – and their health can take a toll.

This is one of the reasons why we received over 34,000 visits from people over the age of 65 in the St. Joe’s Emergency Department and Ambulatory Care Centre last year.

“We’re in a corner of the city with the oldest demographic in the GTA right now,” adds Dr. Tal.

These patients are referred to the ECHS clinic for an in-depth assessment, featuring an integrated, interprofessional approach to care. Patients have access to experts to help manage their health and other issues. These experts span various disciplines, including geriatric medicine, nursing, occupational therapy, speech/language therapy, social work, physiotherapy, and registered dieticians.

Geriatric care requires a comprehensive approach, according to Dr. Tal. “We have to focus on the entire person,” he says. “Their heart, their brain, their lungs, their diabetes, their support structure, and their cognition. That’s how we do our best to serve the community around us.”

It’s a wonderfully gratifying job, he adds. But it’s also a tough one. While caring for patients – including “orphan” seniors – St. Joe’s staff members face the challenge of keeping them healthy when they’re back in the community on their own.

Seniors often need help with bathing, personal care, and healthy eating – which are all long-term issues that last far beyond a patient’s time at St. Joe’s.

That’s why ECHS focuses on linking seniors with a support network. This often means putting them in touch with their local Community Care Access Centre (CCAC) to find assisted living options.

The goal is keeping people in their own homes in the community, while also anticipating the need for long-term care. According to Dr. Tal, many people with no support network thrive in these types of facilities because the group setting increases their odds of taking medication properly and having a healthy, balanced diet. There are also inherent benefits from the social experience of being with other elderly people.

“People eat better when it’s communal dining,” adds Fine.

But when a senior is living alone and coping with the challenges that come with aging, it’s particularly important for family members to check in on them.

“If there’s someone in your family that you think is having trouble – be an advocate,” says Dr. Tal. This means staying involved in their life and paying attention to changes.

In addition, if you notice a senior neighbour isn’t leaving their house or appears to need assistance, consider getting them in touch with resources to help provide care.

“As a community member, you can call the CCAC and public health nurses,” says Fine.

Those services can, in turn, help seniors get a referral to the ECHS clinic at St. Joe’s.

“We want people to know that St. Joseph’s is a place they can turn to with their care needs, specifically related to the issues of cognition, isolation and depression,” says Dr. Tal.