House Calls: First Rate Health Care for Seniors
The determined work of two doctors demonstrates a better way to care for frail seniors. The bonus, says Jayne MacAulay, is that it will save money, too.
“Psst, come here. I’ve got to talk to you,” came a quavering voice calling me from the den. At 96, Syd F.’s health was fragile, but his mind was quick and his sense of humour intact. Now he was quite serious. “I just want you to know I love these people,” he said confidentially. “They are the best.”
The people Syd was referring to are those who comprise House Calls, a mobile team of health professionals that cares for frail seniors in Toronto. It’s led by Dr. Mark Nowaczynski and Heather Taylor, a nurse practitioner. I was joining them on this call, trying to get a sense of what first-rate senior care might look like.
I listened as Nowaczynski and Taylor chatted with their patient. Their conversation was teasing and fond and offered Syd reassurance that he would soon be reunited with his wife, Gertrude, 98, who had been moved to a nursing home six weeks earlier when a kidney infection had suddenly sent Syd to hospital.
“What I’m saying, nobody put me up to,” Syd now confided to me. “You understand?” Of course I did. House Calls’ care had given this couple another precious year together in their own home. And incidentally, it had saved taxpayers thousands of dollars in nursing home costs.
House Calls’ annual budget is $480,000, and Nowaczynski estimates that if his program delays eight long-term care admissions for a year, it will pay for itself. “From a bean-counter point of view, it’s extremely cost-effective,” he notes. Technology adds to efficiency. Electronic records accessible on a laptop keep the team current with each patient’s status.
“Since we launched the fully [provincially] funded program in September 2009, we’ve enrolled close to 300 patients. House Calls’ oldest patient recently died at home at 105, he says. “She was flirting with me two days before her death.”
But it wasn’t until last year that a chance hospital visit of one of Nowaczynski’s patients rounded out the House Calls’ circle of care. The patient was Mr. W., a 101-year-old Second World War refugee from Poland, who had worked as an architect in Canada. In his late 90s, he’d been enrolled in House Calls because of medical issues. One Friday, he had a fall, and his worried son rushed him to Toronto’s Mount Sinai Hospital. In the emergency room, a geriatric emergency management nurse flagged his file for Dr. Samir Sinha, the hospital’s new and forward-thinking director of geriatrics.
By Monday morning, when Sinha met Mr. W., after two days in bed (with the inevitable catheter and IV), he didn’t want to get up. The man who could use his walker the previous Friday now required two people to help him to the bathroom.
Sinha offered two choices: either get moving and return home or expect to go to a nursing home. Sinha had Mr. W.’s catheter removed, had him sit in a chair for meals, had him work with the occupational therapist and physiotherapist and called in a MAUVE (Maximizing Aging Using Volunteer Engagement) volunteer. (The volunteer even turned out to be a Polish speaker.) Sinha consulted Nowaczynski about the patient’s complex pain issues. Two weeks later, Mr. W., using a walker, left the hospital and returned home.
Three months later, Sinha made a follow-up visit at Mr. W.’s book-filled condo. (How many specialists make follow-up house visits?) The 101-year-old had been busy writing his memoirs on his computer.
Sinha is both a gerontologist – an expert in the psychological and social aspects of aging – and a geriatrician – an internal medicine specialist trained to diagnose and treat older adults. Typically, older patients have complex medical issues that often require multifaceted care. “Geriatrics is a team sport,” Sinha is fond of saying. This past April, Mount Sinai Hospital opened a 28-bed Acute Care for Elders (ACE) medical unit, with its own team: a nurse practitioner, occupational therapist and social worker. Nurses and other staff on the unit receive 19 hours of advanced training to raise awareness of various geriatric syndromes. Subtle changes like non-glare floors and outlining patients’ room doors in contrasting paint make the ACE unit less difficult for the physically or cognitively impaired.
At the weekly “rounds,” I join Sinha as he meets with his team – which also includes a resident in internal medicine, a pharmacist and the House Calls nurse practitioner – to assess each patient’s progress. It’s where I first heard Heather Taylor mention Syd F. She’d sent him to hospital on New Year’s Eve, delirious as a result of a kidney infection. For years, he’d been the primary caregiver for his wife, Gertrude, who’s been slipping deeper into dementia. While their daughter, Susan, saw to Syd in hospital, Gertrude, who couldn’t be left alone, had to be admitted to a nursing home on a crisis basis. Taylor reports that House Calls is arranging for the couple to be reunited in a long-term care facility.