From “falling through the cracks” to restored health and independent living

Darlene Caprice landed in a Hamilton Health Sciences (HHS) emergency department last winter after suffering a fall. Since then, HHS’ award-winning Hospital 2 Home (H2H) program has been helping the 69-year-old woman regain her independence and stay safe from COVID-19.

HHS’ H2H program provides care for patients impacted by multiple chronic conditions and faced with social and economic barriers to good health. The program’s goal is to improve patients’ health outcomes and well-being, which often results in less trips to the emergency department and fewer hospital admissions.

“I’m so impressed by the H2H program.”

While being treated at the emergency department, it was discovered that Caprice had a number of unaddressed health issues including malnutrition and deteriorating eyesight due to cataracts.

She was referred by the emergency department to the Centre for Healthy Aging at HHS St. Peter’s Hospital where she received a comprehensive assessment. When Caprice shared that she had no way to get to her assessment appointment, the Centre arranged for transportation. The Centre also made a number of life-changing referrals for personal and health care, including to HHS’ H2H program.

Building trust

“Our team was able to ‘take the torch’ from the Centre for Healthy Aging, to help Darlene receive the care she needs on an ongoing basis to get back on track,” says H2H coordinator Jill Traynor, who received Caprice’s referral last January. HHS’ H2H program together with its community partners has been providing support ever since.

“Darlene had completely fallen through the cracks.”

H2H partners with patients to co-design coordinated care plans based on what patients identify as most important and concerning to them about their health. Assessments are completed in the community to determine patients’ unmet health and social needs.

“Darlene had completely fallen through the cracks,” says Traynor. She had been living in isolation with no family or friends to help her. Today, thanks to H2H’s involvement, she has a mix of health and social supports including H2H.

Fiercely independent, Caprice hesitated accepting support at first. “It took time for her to trust our team and allow us into her world so that we could help her navigate the complicated health and social systems,” says Traynor. “Thankfully she came to trust us, and by extension she came to trust the care team we helped build around her.”

Seeing the light

“I’m very thankful for all of the help that I’ve been getting,” says Caprice, whose quality of life has improved dramatically. “I really like everyone who’s been helping me.”

“I can see the raindrops on my balcony.”

Deteriorating vision due to cataracts impacted almost every aspect of Caprice’s life. “She couldn’t see us when we came to visit,” recalls Traynor. “Everything from grocery shopping, to attending appointments, to taking out the garbage had become increasingly challenging.”

With H2H’s assistance, Caprice was referred to ophthalmologist Dr. Anne Beattie for cataract surgery in August and is thrilled to have her sight back.

“I’m so impressed by the H2H program,” says Beattie. “The H2H team helped this patient pursue life-changing eye surgery. I think the amazing thing is that we have this program in our community.”

H2H supported Caprice by attending appointments with her and helping her organize care before and after surgery.

“I can see the raindrops on my balcony,” Caprice told Traynor during a recent visit.

Meeting wide-ranging needs

Failing eyesight, combined with the pandemic, kept Caprice largely isolated in her apartment for months, says Megan Frechette, an H2H community health navigator.

“While Darlene had a family doctor, she hadn’t seen him in years and wasn’t aware that he had retired,” says Frechette. “We helped her connect with the new doctor who took over the practice. The team also helped Darlene renew her OHIP card, which had expired.”

Caprice had been surviving on a small inheritance that barely covered her monthly rent and food. She had never applied for government pensions, so the H2H team helped her apply for the Canadian Pension Plan, Old Age Security and Guaranteed Income Supplement, including retroactive payments. H2H also connected her to a financial trustee for support with rent and bill payments.

“I really like everyone who’s been helping me.”

When in-person appointments weren’t possible due to the pandemic, H2H supported her with virtual visits by telephone or video conferencing. H2H also organized accessible transportation, and with support from the HHS Foundation through the Sherman Family Food Grant, Meals on Wheels was also arranged.

While Caprice was aware of the pandemic and wanted to get vaccinated, she wasn’t able to book an appointment or attend on her own. H2H partnered with the Hamilton Community Paramedic Program so Caprice could be vaccinated at home.

Other supports included connecting her to a pharmacy that delivered medications and partnering with Home and  Community Support Services to arrange for a personal support worker to visit her daily.

Caprice is thrilled that her quality of life has improved so much since HHS’ H2H team entered her life.

“I would never have known how to get in contact with all of the people that are helping me. Everything turned out really well.”