James Meloche, CEO of Community Care Durham, said over the past 45 years, their job has been to help people live in their homes in the community just east of Toronto, independently.
Community Care Durham serves 9,000 clients on average, and 400 of those clients require daily support.
“Many people are living at home,” said Meloche. “Ten years ago, they would have been living in long-term care.” While he said it’s great that more people are living at home, the worry becomes, “how do we support them?”
With that goal in mind, a program was kicked off late last year to bridge the gap between community and hospital.
“Our goal here is to really be in front of those who need help, and be an accelerator to get them to the care they need,” said Meloche. He said that the concept is to help ease the burden on emergency departments by having nurses from Community Care Durham check in on patients and be that gap to fill “non-emergent” cases. Meloche said that this highlights a growing need, as the health-care system continues to be overrun in the province.
“It’s almost like people require an accident or disaster or negative experience that leads them into the health-care system, and only then is actually when they have access to the services they need,” he said.
But, Community Care Durham has the goal of providing care before it gets to that “emergent” point. “When they get there, their health deteriorates really quickly,” said Meloche, adding that through research, the CCD has found that seniors lose 10 per cent of their function for every single day they spend in the hospital, and for someone with other health issues, that rapid decline can be life-changing.
While the program is filling a much-needed gap, they’re starting small. The program currently has two nurses and support staff. These nurses also provide support, advocacy and assistance to patients who already have personal support workers (PSWs).
Things like falls or confusion over medication may not be emergent, but they can cause someone to spiral at home, which then leads to them going to the hospital.
Rebecca Kollaard has been a resource nurse with the CCD since the program launched in late 2022. Now, she helps clients, goes to their homes, assesses and assists them.
“For all clients, it starts with an assessment,” said Kollaard. “Decide from the assessment what they need going forward, and see what else they need to stay being independent.” From checking vitals or a wound that the patient is unsure of how to care for, to helping out with a new prescription, the range of what they can assist with is wide.
Alison Eames, also a nurse with the program, said it really helps in ensuring that no one falls through the cracks. So far, even though the project is in its early stages, it’s been a success.
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“We did have someone who had suffered a traumatic wound recently. They went to the hospital initially, but the wound did look like it was getting infected,” said Eames. “We then collaborated with the doctor because we were concerned, and we were able to help him and prevent him going through another hospital visit.”
Along with lengthy wait times, many seniors don’t have the ability to make it to appointments outside of their homes, or even get to the ER when they need to.
The hope is to build on the program’s success thus far, to grow it bigger, and to really assist patients, their families and care partners, as well as ease the pressure on hospital systems.
Meloche says the need for targeted home care will continue to grow. “There is an ongoing demand for this service, it’s not like it’s going away,” he said. “In Canada we need to do a much better job at keeping people at home where they want to be.”
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