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How two innovative programs are transforming seniors’ health care at MSH

By Vawn Himmelsbach

After spending eight months in hospital, Brenda Okapiec was ready to go home. She had been diagnosed with ovarian cancer and after her first chemotherapy treatment, acquired a blood infection that landed her in the ICU.

Brenda spent a month on life support and was eventually moved to complex continuing care where she had to learn to walk again. “I still have a long way to go,” she says. “But nobody thought I’d be here today.”

‘Here’ happens to be her home in Markham, where she lives with her husband and son. While Brenda gains back her strength before another surgery this spring, she receives daily medical care in the comfort of her own home, thanks to a brand-new program offered by MSH.

Brenda is one of the first patients to take part in the MSH @ Home program, which started last November. Staff from MSH and Bayshore Healthcare (Bayshore)—a provider of home and community health care services— identify the specific services an individual may need, such as physical therapy, occupational therapy, nursing or personal support, and create a customized care plan for up to four months post-discharge. Patients know the name of their care provider, when they’re scheduled to arrive and what they’re scheduled to do.

The program helps to facilitate an early discharge from hospital by providing enhanced care services in the home. It’s designed to support seniors at risk of becoming Alternate Level of Care (ALC) patients — those occupying an acute care hospital bed while not acutely ill — but still requiring additional support.

At first, Brenda was “a little leery” about strangers coming into her home, but she’s pleased with the high level of care she’s receiving. A nurse comes each day around the same time to take her vitals, and a physiotherapist visits three times a week.

“Eight months is a long time to be in the hospital,” she says. While she’s happy to be back at home, the peace of mind the program provides is also a huge benefit. “My husband helps a great deal, but it’s nice there’s a nurse there to help me for an hour or two every day.” And it gives her husband a break from round-the-clock care.

“MSH @ Home focuses on seniors who may have had long hospital stays,” says Maria Easow, ALC coordinator at MSH, who works with patient flow coordinators to identify and refer patients to the program. “It’s a seamless transition — there is one contact person for these patients and their families, providing more consistency of care.”

Bonnie Jean-Baptiste, MSH’s ALC patient care manager, adds that there’s also a 24/7 telephone line should someone need to call after hours. “We’re tailoring the services specific to the patients’ needs, and these services can adapt as their individual needs change,” she says.

In addition to MSH @ Home, the hospital has also introduced the Integrated Care Transition program. This program, which kicked off at the start of December 2019, is designed specif-ically for patients awaiting placement in a long-term care home. MSH works collaboratively with Bayshore to identify up to 15 patients at a time who will have the option to move into Sunrise Unionville, a Markham-based retirement home, while waiting for a long-term care bed to become available. While Sunrise Unionville is not equipped to support seniors with active medical conditions, it does have a physician on staff who services the entire facility.

“Markham has the lowest number of long-term care beds and a fast-growing population of people over the age of 65, so we find our hospital is under pressure to provide service for this vulnerable population that doesn’t need to be in hospital,” says Bonnie.

While there are several well-respected long-term care homes in Markham and Stouffville, they tend to have long waiting lists. Many patients want to remain in their own community, close to family members, so they’re reluctant to choose a long-term care home outside the area — particularly if it means an elderly spouse will face a long drive for visits. Some are also on waiting lists for culturally specific homes.

Read the full article from the Winter 2020 Healthy Together Markham Stouffville Magazine.