Primary Care @Home

Primary Care @Home

Learning About Us

We are a small team that is dedicated to supporting people who are in the last chapters of their life and who have trouble leaving their homes because of infirmity (changes in their health that prevent thriving). It is an honour for us to be welcomed in peoples’ homes. We take this privilege seriously!

Our core team includes a medical administrator, a physician assistant, a social worker and a physician.

We also work closely with a care coordinator from the Local Health Integration Network (LHIN) – sometimes called home care and pronounced “LINN.” If possible, we try to have Kathy Gleizer become the care coordinator for the people we support so that we can connect easily.

We also collaborate with other people who are involved in supporting you, as long as you are comfortable with this.
Sometimes, people think of life as seasons – spring is from birth to around 20 years old; summer is from around 20 to 40 years old; autumn is from 40 to 60 years old, and winter is from 60 until a person dies.

We feel called to support people who are in the winter of their lives.
We hope to support people who want to experience their final season in their own home rather than in a hospital or other institution, when this is possible.

We care very much about helping people improve their quality of life. In other words, we focus on good days rather than more days.
Our intention is to respect the dignity and wisdom of the person who wants our support while also empowering their supporters so that they can thrive as well.

 

How Can We Help?

If what we can offer resonates with you, please review this collection of criteria to ensure we’re on a similar page before exploring the next steps:

Please answer these questions to see if you or someone you support can
receive support from the Taddle Creek Home Visiting Team:

YES or NO

Do you live within this part of Toronto? Between Lansdowne (to the west), Yonge (to the east), St. Clair (to the north), and Lake Ontario (to the south)

YES or NO

Would you like to experience the final chapters of your life at home, including your death, if possible?

YES or NO or MAYBE

Is your family (or friends or circle of support) willing to support your decision to remain and die at home (if possible)?

YES or NO

Do you rarely leave your home due to your health challenges? Do you find it very difficult to see your nurse practitioner or family physician?

YES or NO

Do you have several health conditions that require a lot of energy? (This may include issues like arthritis, heart problems, and mindrelated challenges.) If your main health problem is a cancer, then another home-visiting team may be a better fit for providing the best possible care for you.

YES or NO

Are you willing to transfer your medical care from your current family physician or nurse practitioner to the Taddle Creek Home Visiting Team?

YES or NO

Do you want to avoid medical tests and treatments that take place outside the home (like stays in the hospital?

YES or NO

Are you hoping for a natural death? (Or do you want people to try to bring you back to life using technology (like chest compressions, electricity, and breathing tubes)? If you are hoping to be brought back to life, then our program is likely not the best fit for you. If your hope is to die naturally, we can complete a Do Not Resuscitate form, which is best placed in a visible location like on your fridge. This form lets paramedics know that you want help to keep you comfortable, though you do not want to be brought back to life when you die.)

YES or NO

Have you chosen a funeral home to provide after-death care when you die? If not, are you willing to choose one?

If a person answers YES to all questions, our team may be an appropriate support for home-based late-life care. If you have questions or would like to discuss possible care, please e-mail Sasha Adler at sadler@tchft.on.ca or call 416-585-9555.

 

What We Can Offer

If your primary care practitioner (for example, your family physician or nurse practitioner) is unable to provide house calls or home visits, we may be able to support you.

  • We can help you explore what matters most to you in this final season of your life and can create an approach that best reflects your values and what is available to you in this time of your life.
  • We can visit you in your home approximately once-per-month to explore ways to help you thrive, calling on modern medicine and integrative medicine to address difficulties you may be facing.
  • Some ways we can help you have better days can include optimizing your prescription medicines (including finding ways to use less of them, if appropriate), acupuncture, and ear syringing
  • We love to collaborate with other experts to help make life as enjoyable for you as it can be. With your permission, we can work with your community pharmacist, wound nurses, dieticians, rehabilitation practitioners (like occupational, speech, respiratory and physio-therapists etc.). We can also connect you with available resources to help you and your supporters thrive.
  • We can provide health care in your home. If you are determined to stay at home rather than go to a hospital, we can offer hospital-at-home if you develop a sudden (and sometimes final) illness. This type of care is a bit like “pioneer” or “old country doctor medicine;” while we will use the most up-to-date medical research to inform how we care for you, we will adapt the care based on your desire to remain at home.
  • When it becomes clear that your time to die is near, we can provide care that is unique to you and that honours your wishes in this final, sacred chapter for you and the people who care about you. We can provide palliative care to reduce uncomfortable symptoms.

 

How We Support Each Other

  • When we visit your home, we will arrange for our next visit before we leave. If you have questions that come up between our visits, please write them down so that we can explore them at our next visit with you.
  • We will leave a written summary with the date of our next visit and recommendations that came from our visit.
  • If a health concern arises between our visits and you want our help, please call Rose to let us know what is happening. If you give Rose a description of the situation, she can connect with Andrea (our team coordinator and physician assistant) more effectively. It is very important that you tell Rose if the issue is urgent or if it can wait. This helps us use limited resources as well as we can.
  • Please be patient with us! We are a small team and care for approximately forty people who have trouble leaving their homes due to their serious health challenges. Often, at least one person we support is actively dying at home. This means that we set aside time to see them each day to help them die as peacefully as possible. Other people may be having a flare-up of their heart disease or be suffering from a serious infection, so we see them frequently as if they were in the hospital. We try our best to balance the needs of each person and their family/circle of supporters.
  • Please also note that, when we are not providing home visits, each team member has other responsibilities. Rose runs a whole clinic with many different health practitioners and thousands of patients. Andrea helps out in several clinics and is an expert in assessing peoples’ breathing. Sasha provides support for people in the Social Work program in several clinics. Kathy coordinates care for many people and also works in the urgent care department for help people with unexpected challenges. Dr. McMurren leads a clinic at Toronto Western Hospital, cares for people who are dying in a hospice, and teaches at the university.

For many people, thinking and talking about death is uncomfortable. Mr. Rogers famously said that if something is mentionable, it becomes manageable. If you have questions or worries about your death or the death of someone you care about, feel free to talk to one of the Taddle Creek Visiting Team members.

Should you have questions, please feel free to e-mail Sasha Adler (sadler@tcfht.on.ca), e-mail Andrea Filip (afilip@tcfht.on.ca), or call (416) 585-9555.

 

How will I know if my loved one (or myself) is sick enough to require services of the Primary Care@Home program?

This is not always easy to determine, but one tool that can help make this determination is the 'Clinical Frailty Scale' (see downloads). If your loved one (or you) scores 5 and above, you may benefit from the services of the Primary Care@Home program.

Do I have to switch doctors to be a part of the PrimaryCare@Home program?

Generally yes.

If you are a current patient of Taddle Creek, you may be able to keep the same primary care provider, however they may not be the provider who does regular home visits.

If you are not a current patient of Taddle Creek and are accepted into the program, there will be an introductory home visit to ensure all parties are comfortable transferring care.

Is there a PrimaryCare@Home wait list?

There is no formal PrimaryCare@Home wait list kept at Taddle Creek FHT.

Capacity will be updated on our website quarterly. Contact our Program Coordinator, Andrea Filip, at 416-585-9555 to discuss potential referrals.

Is the Primary Care@Home program accepting new patients?

We are currently at capacity, but this changes frequently.

We accept 2 new patients per month at most when not at capacity.

Who is eligible for the Primary Care@Home program?

Those older than 65 years of age who are unable to access primary care in the clinic for medical, cognitive or social reasons, and who live in the listed catchment area.