New care model to better support vulnerable seniors

As Ontario prepares for a growing seniors population, healthcare providers are increasingly focused on developing new strategies to better support them. Seniors often have complex conditions that require frequent care and monitoring. One condition that has received considerable attention for this reason is dementia.

While dementia is commonly believed to be a natural part of aging, it is actually a degenerative neurological disease that affects a person’s memory, behaviour and ability to perform everyday activities—it’s also one of the major causes of disability and dependency among older people.  A 2016 report by the Ministry of Health and Long-term Care found that one in 10 seniors in Ontario lives with some form of dementia. Seniors who have a chronic disease, such as heart failure or diabetes, in addition to dementia, are considered to be at greater risk for poor health outcomes.

“The traditional model of medicine looks at each part of the body separately,” says Dr. Fiona Menzies, Chief of Geriatric Medicine at St. Joseph’s Health Centre in Toronto. “When we’re working with seniors who have more than one illness, we really have to look at the whole person to understand how they will respond to treatment.”

This holistic approach is particularly important for seniors who are frail and may not be able to tolerate medical and surgical treatments that tend to benefit healthier people. Geriatricians must work closely with other specialists, as well as patients and their caregivers to help patients consider all of their options. Historically, collaboration across medical disciplines has been challenging.

“How I define frail may not be how a cardiologist would define frail,” explains Dr. Menzies. “We need a common understanding of a patient’s condition in order to determine their treatment options.”

The Palliative Care and Therapy Harmonization Model (PATH) is a new model of care, originally developed by physicians in Nova Scotia, that tackles the challenge of coordinating care for seniors with serious illnesses. PATH creates a standardized method to assess how frail or vulnerable a senior is which gives physicians a shared understanding of a patient’s condition and the impact different treatment options can have on their quality of life. In January, St. Joe’s launched the PATH program in the cardiology department, with plans to expand to the nephrology and oncology department in the coming months.

“For patients to make decisions that are right for them, they need to understand their condition and the risks and possible benefits of each treatment, and how they are likely to respond,” says Dr. Menzies. “PATH enhances our ability to collaborate, not only as doctors, but with patients and families as well.”

Family members and caregivers play a critical role in caring for patients with dementia because as a person’s cognitive function declines they may not fully understand their medical condition. Families often have questions about how to get the most out of life, how to make health care decisions and how to manage symptoms and plan for what lies ahead. It is a challenging conversation, but our interprofessional team works closely with caregivers at every stage of the process.

“Dementia used to be like cancer – it was a word people avoided,” says Dr. Menzies. “Now I find families really appreciate the frank conversations we have about a patient’s condition—it empowers them to make decisions that reflect the patient’s needs and life goals.”

St. Joe’s sees 28,000 seniors annually across our programs and this new model promises to enhance the way we care for the most vulnerable among them.

Alica Hall is a Communications Associate at St. Joseph’s Health Centre in Toronto.

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