Program helps seniors remain at home safely

February 21, 2019 - “We’re always surprised by the depth of information. They’re able to identify early health issues that are beginning to arise, and we can assign resources to patients before they need intervention, which is what makes such a big difference.” says David Price.

NIAGARA-ON-THE-LAKE - In an era of troubled health care, and in a town where the demographic bulge is in the 60-plus set, McMaster University’s Health Tapestry program is a beacon of hope and support.

The program partners trained volunteers with residents 70 years of age or older, to determine any health care needs that may not be being met by their current resources.

The volunteers are provided, certified, and trained by the Red Cross. A pair of them visits a senior at home, bringing with them an iPad loaded with an in-depth questionnaire.

The home visit allows volunteers to survey the living situation in a way a family physician couldn’t, and also gives them the luxury of time for questions and answers, to create a thorough assessment of the patient’s health.

As Dr. David Price — one of the originators of the program — explains it, “I always hear from clinicians that volunteers bring back information they didn’t know. If they come into our office for a diabetes check-up, they don’t tend to say, ‘By the way doc, I’ve had a couple of falls recently.’” He continues, “We can’t ask every single question,” in the short period of time of an office visit.

“The volunteers have sat in their living room with them and had tea and asked questions,” he says. “We’re always surprised by the depth of information. They’re able to identify early health issues that are beginning to arise, and we can assign resources to patients before they need intervention, which is what makes such a big difference.”

The physician recounts a personal experience with the program: “A couple in their mid-seventies have been my patients for 19 years. Seventeen years ago I delivered their grandchild,” he says. “I thought I knew that family really well, but I was surprised by the information that came back with volunteers about that couple. They were more frail than I had realized, they had more potential health issues. This enabled me to be more proactive than reactive.”

The impassioned doctor continues, “The goal is the longest possible quality of life at home. We asked, ‘As a family doctor, could we improve our patients’ health care journey?’ We realized we can improve quality of life if we interview them early. And you start to realize cost savings, decreased hospital visits — a virtuous circle.”

Julie Datta, the program manager, explains the information from the volunteers goes to a team of medical workers, including a dietician, mental health nurse, outreach nurse, occupational therapist, and the patient’s physician. “We huddle the team to look at the report,” with the end goal always being to keep people out of both emergency and extended care. With a group of experts accessing such in-depth information, “we can think outside of the box,” she says. “Stories get told, and the application gets synthesized into a story for their family health team, to help people live a better quality of life at home.”

A successful run has been completed in Hamilton, with 380 patients seeing reduced hospital visits and stays, and declined emergency and urgent care visits. Six sites are now being tested across Ontario, there is an agreement to work in Nova Scotia, and there’s interest in Quebec and out west. Niagara-on-the-Lake was a prime candidate for the program, says Price, due to the lack of a local hospital, as well as the history of a strong volunteering community.

Marilyn Robson is one of the 13 volunteers based in NOTL. With her background in nursing and management of long-term care facilities, retirement complexes and home care agencies, she was a rather ideal candidate for the position. She says the group is quite diverse, with a nice representation from different demographic groups: young and old, retired and working.

Robson describes the questions, designed by a team at McMaster, as “very non-invasive,” and says it takes a little more than an hour to complete the assessment. She enjoys working with the program — in fact, “I love it. I love it.”

Her only issue is concern over the future of health care. “My frustration is that if we can’t convince the government — we have to convince them to put money into community support and long-term health care at home. We don’t want people stuck in the hospital,” she says. “We need to put enough supports in place to keep people at home. Many patients need someone two to three times per day to make sure they’re eating properly, taking meds, getting ready for bed — that’s where we need the money for health care. This is a very helpful program, because a lot of people don’t know how to access supports.”

Debbi and David Frisby live in Virgil, and have completed their round of interviews with the Tapestry program.

Debbi was diagnosed with Parkinson’s Disease in 2011, and subsequently had a bad fall at home, two days before Christmas, in 2016. These two health issues left the retired nurse diminished, and put her husband, David, to work as a full-time caregiver. “Life can throw you a curve ball,” says David wryly.

David — also retired from the medical industry — learned many of his skills in this new field during Debbi’s extended stay in the hospital. The fall, it turns out, had been serious enough to break her spine (this was tragically discovered after a misdiagnosis and prolonged agonizing pain). Both of the Frisbys are extremely grateful to their family physician Dr. Tim Bastedo of the Niagara North Family Health Team, for everything he has done for them — including encouraging them to sign up for the program. “I can’t praise him enough,” says David, tears springing to his eyes.

Through the program Debbi was seen at the Swallowing Clinic in St. Catharines, to ensure the Parkinson’s was not interfering with her nourishment and hydration. And an occupational therapist was sent to their house to show Debbi some things she could do differently to avoid further falls.

The Frisbys had already arranged for a personal support worker and a March of Dimes volunteer to help Debbi with bathing and dressing. “I’m not in a hospital or a home,” Debbi says with some relief. “We take everything in our stride,” says David.

Patients of the Niagara North Family Health Team can self-refer to the Health Tapestry program via the clinic, or can be referred by their physician or a family member. You must be 70 years of age or older to participate. More info is available through the Niagara North Family Health Team, or at

As Dr. Price says about the only program of its type in the world, “I don’t think anybody who hears about it thinks it’s a dumb idea.”

Source: The Niagara-on-the-Lake Local, Lauren O'Malley.