House calls: A new vision of elder care

A bout of pneumonia combined with a bad fall could have been disastrous for a 100-year old man living alone in a Toronto apartment. The fall inevitably meant hospitalization and, for many older adults, a hospital stay is seen as a setback, a journey that often takes an older person out of the home-setting forever.

But a revolutionary partnership changed the outcome for Mr. W, and laid the groundwork for a new vision of elder care in Canada. “We’ve created a hybrid model of home-based, primary and specialty care for frail seniors,” explains Dr. Mark Nowaczynski, Mr. W’s family physician, and a new addition to Mount Sinai Hospital’s Ray D. Wolfe Department of Family Medicine.

Dr. Nowaczynski is the pioneer behind House Calls, a project reminiscent of a time when the doctor was at the patient’s doorstep instead of in an office. He created House Calls in 2007 as a pilot project, and received full funding from the Ministry of Health and Long Term Care in 2009. The program brings together an inter-professional team made up of a physician, nurse practitioner, occupational therapist, social worker and a coordinator to provide care to some of the most vulnerable in society — marginalized, house-bound seniors.

In November 2010, House Calls forged a unique partnership with Mount Sinai Hospital, and Dr. Samir Sinha, the new Director of Geriatrics at the hospital. Dr. Sinha formed an integrated and inter-professional team to deal with every aspect of an older person’s care in hospital with the hope of returning that patient to the home, when possible.

When Mr. W arrived at the hospital, already on antibiotics for pneumonia, Dr. Nowaczynski’s “heart sank.” A hospital is not always the best option for a frail, older person. An older person can be particularly vulnerable to suffering functional decline in hospital, and one in three older adults discharged from hospital leave with a higher level of disability.

In previous months, Dr. Nowaczynski’s House Calls team had worked tirelessly with Mr. W, helping him lead a largely independent life. The older man had made great strides; he went from a bedbound man to one who could travel up and down the elevator to visit the plaza below his apartment building.

But Dr. Sinha and his team, continuing Dr. Nowaczynski’s philosophy of care, gently approached Mr. W in hospital and asked him an important question. “If we can get you better, where do you want to go when you leave Mount Sinai,” Dr. Sinha asked his patient.

“I want to go home,” said Mr. W.

Mr. W is one example of how the traditional model of care is changing in Canada.

Systems of care in the country developed at a time when the population was younger, and generally healthier. Patients who visited the hospital usually had one issue, and it made sense for a person to be treated by one unit or one program.

Today, older people may suffer from multiple chronic conditions, hospitals are overwhelmed with an increase in the number of older adults, and the situation isn’t going to improve.

Baby boomers started turning 65 this year and by 2030 Canada’s 65 plus population will double. The population for those 85 and older will quadruple.

“Mount Sinai’s partnership with the House Calls program hopes to transform health care in Canada,” says Dr. Sinha. He can now make sure a patient receives the best possible care, whether that is in the emergency department, on inpatient units or outpatient settings or even in the home. “I can tell you this, no other hospital in Canada has been able to develop such a true continuum of care,” adds Dr. Sinha.

“The House Calls program fills a gap,” says Dr. Nowaczynski, and it makes a difference to people who, otherwise, would not have been able to access clinical care. “I’ve come across patients who could only get to their family doctor’s office if they booked an ambulance and paid three hundred dollars.”

“One woman told me she sometimes had to decide between going to see the doctor or eating, and hearing things like that gives me a wave of nausea,” he adds. Dr. Nowaczynski has strived to give a voice to the elderly in the health-care arena, and he sometimes takes his camera with him during visits to capture poignant images of willing patients in their homes.

For Mr. W, after two weeks of care at Mount Sinai, where he underwent aggressive therapy to help him walk again, he was able to return home.

Dr. Sinha and Dr. Nowaczynski stopped by Mr. W’s apartment several months later for an in-home geriatric consultation, and were greeted by a smiling man who was on his feet and ready to entertain. Mr. W, a “true polish gentleman,” had laid out a delicious spread of pies, treats and coffee for the doctors.

“We have to adapt our system to meet the needs of our highest users. By doing that, we can preserve independence, and we can allow people to keep living longer and living well,” says Dr. Sinha,” referring to Mr. W’s successful plan of care. “More importantly, it allows 100-year-old patients like Mr. W to remain in their own homes, which is where they want to be, and where they can thrive.”

Mr. W turned 101 on February 17, 2011. Dr. Nowaczynski indicates he continues to do well.