​View the promotional video above to learn more about the unique program.

By: Parisa Mehrfar, RD, MBA, PMP, MSc, CHE, Manager, Integration and Planning Transitional Care (@home) Programs,
Eastern York Region North Durham Ontario Health Team

The Eastern York Region North Durham (EYRND) Ontario Health Team (OHT) launched Ontario's first and unique Seniors Home Support (SHS) program in May 2021. SHS is an integrated primary care program delivered by an interdisciplinary team to home-bound seniors who for medical, social or cognitive reasons cannot access office-based primary care services.

Seniors commonly have more complex medical needs which require heavy utilization of expensive acute care services. The costs associated with seniors' care accounts for 45 per cent of provincial and territorial governments' expenditures. Home-bound seniors have limited access to traditional office-based care, making it difficult to seek medical attention when needed. This delay results in a decline in patients' health status, an increase in severity of their illness, or increased hospitalizations. Through the SHS program, a dedicated care team provides patients with integrated care at home. This team includes primary care physicians and a nurse navigator, team coordinator, nurse practitioner, occupational therapist, social worker, pharmacist, chiropodist, community paramedics and a dedicated home and community care coordinator.

"It has been a privilege for the SHS team to provide house calls for home-bound patients in our community. Many patients and caregivers can feel isolated and helpless managing difficult illnesses alone at home, especially during the COVID-19 pandemic. It has been an honour to walk alongside our patients, bring medical expertise and guidance, as well as a renewed focus on their' personal values about where, when and how they want to be cared for. Our goal is to continually improve our program to provide accessible, responsive, and patient-centred care for each individual," says SHS program team member.

SHS is an example of system integration between Oak Valley Health, Markham Family Health Team, South East Geriatric Outreach Team of the New Unionville Home Society, York Region Paramedic Services Community Paramedicine Program and Home and Community Care Support Services – Central Region. Through the SHS program, currently, existing resources are coordinated to improve efficiency while avoiding duplications in assessment, testing and service delivery. Care occurs through a single electronic medical record (Accuro) that offers patients a more connected, seamless, and person-centred experience.

"My mother-in-law became part of the Senior's Home Support Program (formerly the Hospital to Home Program) when she was discharged from Oak Valley Health (formerly Markham Stouffville Hospital) in April 2020.  With her mobility issues, it gave our family a sense of relief that she was able to get care at home from the medical community.  From our very first virtual meeting, Dr. Mui stood out to be a caring, attentive and meticulous physician with a great bedside manner. We are forever grateful that my mother-in-law was part of the Seniors Home Support Program. Having a program that allows for vulnerable seniors to be cared for in their homes is invaluable," says Pauline Tam, caregiver.

To remove barriers to access, SHS accepts referrals from hospitals, medical professionals, community service providers, as well as patients and their caregivers.

The image below outlines the patient journey map from referral to discharge.

Since the launch of the program, unnecessary emergency department visits have been reduced by 30 per cent and the program has received funding to hire two additional full-time primary care physicians from the Ministry of Health's alternative funding plan. This funding will ensure that the program can be expanded to improve access to care for additional home-bound seniors.

To be eligible for the SHS program, seniors:

• Are 65 years or older
• Have a valid OHIP card
• Live in Markham or Stouffville
• Are in need of a primary care practitioner
• Are homebound and unable to attend in-person medical appointments for medical, social or cognitive reasons

For more information about the SHS Program, please visit eyrnd.ca/community-partners/seniors-home-support