Award-winning H2H program helps patient stay independent

Last winter, Renee Rosenthal felt like a prisoner trapped in her second-floor apartment. Severe osteoarthritis and spinal stenosis made walking extremely difficult for the 65-year-old Hamilton woman, whose building had no elevator.

Now, thanks to support from Hamilton Health Sciences’ (HHS) award-winning Hospital 2 Home (H2H) program, Rosenthal has a new apartment, new hip and the community supports to live comfortably.

“It would take me about 10 minutes to walk down the stairs to the main floor,” Rosenthal said of her old apartment.

In spite of significant mobility challenges she managed to keep her pain clinic appointments at McMaster University Medical Centre.

Rosenthal had signed an agreement to move out of her old building because it was being converted into condominiums, but she had nowhere to go. “I just felt overwhelmed,” she said.

“If I hadn’t connected with the Hospital 2 Home program, I might not even be alive now.”

During a pain clinic appointment last winter, Rosenthal shared details of her day-to-day struggles with a social worker, who contacted the H2H program.

Success based on community partnerships

H2H provides care for patients impacted by multiple chronic conditions and faced with social and economic barriers to achieving good health. Since the program was established in 2014, it has supported close to 1,400 patients in the Hamilton and Niagara area.

H2H’s success is based on strong community partnerships. The H2H team collaborates with patients and health, social and community service providers to create action plans that support patients’ goals while also improving the patient and provider experience, population health and the use of health care resources.

“When I met with Renee last December, I asked her what she felt was most important and most concerning to her,” said H2H coordinator Meredyth Bowcott. “Renee was especially concerned about her living situation, poor quality of life and lack of mobility.”

Rosenthal was in significant pain due to her conditions. “She walked slowly, with a four-point cane,” said Bowcott. “She was also having difficulty getting dressed. It was very hard for her to get groceries due to the inaccessibility of her building and her mobility limitations.”

Drowning in quicksand

Rosenthal suffered from a number of other chronic medical conditions and she was lonely, having lost her partner of almost 20 years one year earlier.

“I felt like I was in quicksand,” said Rosenthal. “If I hadn’t connected with the Hospital 2 Home program, I might not even be alive now. I want people in the same situation I was in to know that there are people and resources that can help.”

Bowcott worked with a Good Shepherd community health navigator, Home and Community Care and Gwen Lee Supportive Housing to help with assessments and applications for new housing.

“Partners came together to advocate for Renee,” said Bowcott. An apartment unit was secured at Gwen Lee, where supports include laundry, personal care and companionship.

Collaborative efforts

Bowcott accompanied Rosenthal to tour the unit and sign her lease. When it was time to move in, Good Shepherd Community Health Navigator Sharon Cammaert accompanied Rosenthal to her new apartment. Cammaert’s role is the result of a partnership between Good Shepherd and HHS, which sees community health navigators partner with H2H coordinators to address patients’ health and social needs.

“It has been quite a journey.”

Cammaert picked up groceries for Rosenthal with H2H grocery gift card donations and continues to support her to attend health-care appointments and address any new care needs. When Rosenthal had hip replacement surgery in spring, H2H continued to support her at home. The Hamilton Health Sciences Foundation provides financial support to the H2H program for items such as food, transportation and other essential supplies.

“It has been quite a journey,” said Rosenthal, who uses a wheelchair but can now walk short distances with a cane.

She is thrilled with the improvements to her mobility, pain management, living conditions and quality of life.

“I never thought, at age 65, I would be in the situation I was in. It’s a cautionary tale. If it hadn’t been for the collaborative efforts of these organizations through the H2H program, I really don’t know where I would be right now. I might not even be around.”

The Canadian College of Health Leaders announced this week that Hamilton Health Sciences is receiving the 2020 Excellence in Patient Experience Award for the Hospital 2 Home program.

HHS team receives Minister’s Medal for health quality & safety (2017)