Geriatric specialists provide in-home care

Earl Sheriff is a 92-year-old war veteran with advanced heart and lung disease and a strong desire to live out his days at his Kitchener home. He has been hospitalized several times in recent years and fears that the next time he will end up in a long-term care facility.

“I don’t want to be separated from my sweetheart,” Earl says of his wife, Gert, also 92 and committed to helping Earl, despite being legally blind.

Although Earl rebounded following his other hospitalizations, he began to struggle at home after a 16-day stay at St. Mary’s General Hospital in Kitchener, Ontario earlier this winter. Weakness and shortness of breath prevented him from leaving home to see his family doctor, who does not make house calls. He receives some home care service, but was reluctant to call an ambulance for fear of being admitted to hospital.


Instead he was referred to an innovative geriatric community outreach service, offered by the geriatrics team at St. Mary’s for frail elderly patients who are housebound and at risk of frequent emergency department visits and hospital admission. The program began in 2011 and focuses on transitional support to address acute issues and chronic disease management with the goal to enhance the quality of care for these vulnerable individuals.

Hellen Jarman, a specialized Geriatric Nurse Practitioner visits referred patients in their homes or retirement homes, an average of two to three times per patient. She can assess them and initiate a plan of care, order diagnostic tests, prescribe medications, provide patient and caregiver education and link them with community services. Many initial visits occur within 24 to 28 hours after discharge from the emergency department. When needed, one of three Geriatricians at St. Mary’s accompanies her on outreach visits.

“This is really state of the art,” Dr. Nicole Didyk, one of the Geriatricians, says of the home visit approach by the geriatric team.  “We want to give the right care in the right place with the right people. If there are barriers to people getting the care they need because of a desperate fear of being separated from their loved one, then let’s go see them,” she says.

Other barriers may include mental health issues, dementia, delirium or physical barriers that mean calling an ambulance is the only way to access care.


In 2013 the outreach team had 143 referrals. They conducted 235 home visits, and 33 retirement home consultations. As a result, 33 per cent of patients avoided an emergency department visit and 34 per cent avoided an admission to hospital. Referrals come from many sources, including the Geriatric Emergency Management (GEM) nurses in the St. Mary’s Emergency Department, as well as inpatient units, retirement homes and the local elder abuse team.

“This is a very patient driven program,” says Ms. Jarman. “We provide them with the knowledge and the tools to fulfill what they want. People do better at home. They’re very engaged and involved because you are respecting their wishes.”

On her initial visit to Earl, Ms. Jarman changed an antibiotic he was on for a recurrence of pneumonia. When she came back a week later, his breathing had improved and he had been able to get out of bed a few times. Dr. Didyk, accompanied her and provided a referral for a visit from a member of the community’s pain and symptom management team. Back at St. Mary’s Ms. Jarman called the Community Care Access Centre and the Department of Veteran’s Affairs to see if Earl could access additional help, as well as the Ministry of Health to request an in-home chest x-ray.


Sandra Hett, Vice President of Patient Services and Chief Nursing Executive at St. Mary’s is fortunate to have so many levels of geriatric expertise to offer within the hospital and outside its walls. “I don’t know of another community in Ontario offering this specialized multidisciplinary approach to outreach and it speaks to St. Mary’s commitment to serving the vulnerable with dignity and respect,” says Ms. Hett.

Dr. Didyk said that while not all outreach patients can be spared a hospital visit, she knows of five or six who would have been admitted to long-term care homes without the care and referrals to community supports provided by the outreach team. “Outreach is definitely keeping people in their homes,” Dr. Didyk says.

Earl, is grateful that his wishes are being supported in a patient-centred way. “It’s what this country needs,” he says.