From Resistance to Persistence to Success!  

By Heather Kuemmling Guelph Family Health Team (GFHT) Primary Care at Home RN

I had the pleasure of meeting Mr. Louis Sartor on October 8, 2013. Mr. Sartor is 88 years old, is widowed and lives alone in his family home of many years. I was asked by Mr. Sartor’s physician to visit him at home to assess for mobility resources as he had recently been asked to stop driving related to cognitive deficits after undergoing the Drive Able Assessment affiliated with St Joseph’s Health Centre in Guelph.

During my initial assessment of Mr. Sartor I met a very pleasant man who was accustomed to caring for himself and proudly shared the fact that he walked to church every Sunday morning. He has two sons who live outside of Guelph but are extremely supportive. I noted several concerns around food and nutrition, self-care, fire and falls. My concerns were discussed with Mr. Sartor’s son at the time of the visit to determine if he too was worried about his father living alone.  My assessment also raised concerns around poor chronic disease management evidenced by high blood pressure and bilateral lower leg swelling, as well as cognitive deficits associated with emergency planning and self-care management.

Upon completion of the initial assessment Mr. Sartor and his son Anthony were in agreement to consider referrals to GFHT foot care clinic for nail care and circulatory assessment, CCAC for an Occupational Therapist to assess for safety and function in the home, and PSW support for personal care based on recommendations from the functional assessment. Anthony was also encouraged to connect with the Alzheimer’s Society for support and education. We also briefly discussed Outreach with St Joseph’s but felt that would be better served at a later date to not overwhelm both the client and family. Anthony and Mr. Sartor also agreed that day to initiate Meals on Wheels, hot meals, to begin the following week in an attempt to improve Mr. Sartor’s nutritional intake. I also requested Mr. Sartor see his physician as it had been years since he was last seen and there was no reports for blood work or head imagery to rule out other causes related to cognitive deficits.  A great Health Links Plan was coming into place with appropriate partners beginning to share care to support this gentleman at home.

As a result of the health link process, of wrapping community supports around Mr. Sartor, he is now receiving care from Personal Support Workers five days per week. Consequently, he now has supervision while cooking breakfast and is receiving proper personal care. He is also more accepting of hot meals delivered to his door and has better supervision to ensure the meals are consumed or stored properly in the fridge. Throughout the week, he has access to extremely valuable informal caregivers within his neighbourhood who continue to assist with orientation and safety. The client continues to see the Foot Care Nurse through the Family Health Team and is receiving regular checkups by the Primary Care at Home nurse and his Family Physician.

Mr. Sartor and his sons each now have a copy of his Health Links Passport document which Anthony describes as “phenomenal”.  They appreciate having a communication tool to be used amongst community partners and the medical team, and an understanding of roles and time lines for each of the community partners. There continues to be more work that needs to be done including ongoing chronic disease management and compliance with medication and treatment orders, as well as social programming and ongoing safety checks. Because of the Health Links process support services can continue to work on these goals together with the client and family and update the Passport communication tool in house for all to see and understand. The Health Links process to date has allowed a man, living alone at high risk, to stay in the comfort of his own home because he is now better supported by the correct community supports at the right time.

For more information:
Guelph Family Health Team
55 Wyndham Street N.
Suite 212
Guelph, ON N1H 7T8
Telephone: 519-837-4444