Unique Outreach Program Cares for Homebound Seniors


Important to our role as a community teaching hospital, St. Joseph’s Health Centre, Toronto, works collaboratively with providers across the health system to ensure that we can meet the needs of our community.

This past summer, St. Joseph’s became one of two sites in the city to launch the Integrated Geriatric and Psychogeriatric Outreach Team for Seniors, an initiative supported and funded by the Toronto Central Local Health Integration Network (LHIN).

This unique outreach team provides in-home geriatric and psychogeriatric consultation and assessment for frail, marginalized, and at risk seniors, aged 65 years and older, because the clients’ health issues prevent them from leaving their homes to seek the care they need, explained Catherine Cotton, Director, Medicine, Ambulatory and Seniors’ Health Program at St. Joseph’s. “There are many outreach teams currently across the province, but this is the first one specifically designed to meet the needs of frail, homebound seniors that have a combination of both physical and mental health and/or addictions issues,” said Cotton. “This combination is the specialty niche for this team.”

“The team works to ensure that clients can get the appropriate care and support through referrals to a variety of community agencies and services, hopefully avoiding unnecessary visits to the Emergency Department and/or admission to hospital because they don’t have access to the appropriate services,” she said. St. Joseph’s is one of six organizations involved in this partnership which also includes the Regional Geriatric Program, the Centre for Addiction & Mental Health, COTA Health, Toronto Central Community Care Access Centre (CCAC) and St. Michael’s Hospital.

The creation of the team at St. Joseph’s (the other team is based at St. Michael’s Hospital) is part of the Toronto Central LHIN’s Aging at Home Strategy, explained Cotton. Under the leadership of the Regional Geriatric Program, a joint proposal identified the neighbourhoods surrounding St. Joseph’s and St. Michael’s as underserviced areas within the Toronto Central LHIN for clients with complex geriatric and/or psychogeriatric needs. The two teams have been created to support primary care providers such as family physicians and community health centres in the care of these frail seniors.

“Many of our clients live alone and have little or no formal support (from family or friends) and it’s their landlord, for example, who checks in on them. It’s usually when someone has concerns about (the client’s) ability to continue on their own that they contact the team,” she said.

While there is no ‘typical’ description of clients served by the outreach team, many clients have complex medical issues. “For example, they may be taking too many medications and not eating well, they may have impaired cognition, or trouble getting around in their home, unable to manage their activities of daily living. They may be isolated, often living alone in complicated social situations or in inadequate housing. They may have had limited access to medical care in the past, or don’t have a family physician. Often, it is just difficult for the client and their family to manage on their own and they need help coordinating the care they need,” said Cotton.

The team, consisting of a geriatrician, psychogeriatrician, nurse practitioner, social worker, physiotherapist, occupational therapist, secretary and two intensive case managers for long-term follow up of clients, conduct home visits upon receiving a referral from the client’s family doctor or concerned family member or friend. Referrals are reviewed by the nurse practitioner and triaged on the basis of urgency of need.

“The nurse practitioner communicates a great deal with the referring physician and/or family member to ensure that adequate information regarding the client is obtained before the first home visit is conducted,” said Cotton. This is done to ensure the appropriate team members go on the visit to assess the client so we can make the most of each home visit, she adds.

Referrals to community resources will depend on the client’s needs and are different for each person. “For example, if the needs concern activities of daily living or social supports, we can refer the client to the Toronto Central CCAC, who determine the right bundle of services that are most appropriate for that client. If there are mental health or addictions issues that need ongoing case management, then the COTA Health case manager will take the lead and work with the client,” said Cotton. “It is all about providing the right care to the client in the right place at the right time, ensuring the delivery of safe, quality care when and where it is needed. This is what our quality agenda is all about at St. Joseph’s.”

“We have a variety of in-house services at St. Joseph’s that we provide for people that can come here, but we have many seniors within our catchment area that can’t get to services,” said Cotton. “The team is a great example of our goal to use our resources wisely in acute care and to enhance the health of the communities we serve by bringing this service to the client’s home.”

Since its inception in August 2009, the team at St. Joseph’s has been successful in providing 329 visits, with 135 new clients referred to the team. Recent surveys of the users of this service indicate a high level of positive satisfaction with the team interventions. This innovative and integrated model of care, delivered by a highly specialized team, is now demonstrating its value in meeting the health care needs of our community.