Frail P.E.I. seniors staying at home longer thanks to 6-year-old program

A P.E.I. program designed to keep seniors in their homes when they are becoming more frail is having success across the Island.

The health-care team that offers the COACH program hopes to expand soon to offer support to even more families.

"This population is the one that uses our health-care system the most," nurse practitioner Megan Smallwood said of seniors who need help with groceries, basic household and hygiene tasks, and medication. 

"It's been so successful because of the team and the village that surrounds these people, but also the participation of the client and the caregiver themselves." 

Since it started in 2015, Smallwood told CBC's Laura Chapin in an interview for Island Morning, the team behind the program has kept participants out of long-term care for two years longer than seniors with similar health concerns who were not involved with the COACH program.

"The data we've gotten so far is that we have cut in-hospital stays by two-thirds, which is significant and saves a lot of health-care dollars," she said.

"We've cut emergency visits by one-third, which again saves a lot of health-care dollars that can be allocated to other areas and perhaps given back to the home care department to again expand the program."

Smallwood said there are about 35 participants in the COACH program in Queens County right now. The program is also offered in eastern and western P.E.I.

How it works

The program gets referrals from nurse practitioners and family doctors, as well as in-home care or other people involved in geriatric care. 

Seniors are then evaluated on what's called the Rockwood clinical frailty score, and those registering a score of six out of nine on the scale are ideal participants. 

A care co-ordinator is assigned to work with a caregiver and "connect the dots in the community" to make sure the seniors get the kind and amount of care they need. 

Attention is also paid to making sure their caregivers — some of whom are themselves elderly — get respite for a chunk of the day so that their energy and health doesn't decline. 

That's the kind of work registered nurse Neisha Fisher does with COACH. 

"It has improved the quality of life of both the caregiver and the client. And it allows them to be home where they want to be," she told CBC.  

As for Smallwood, "My role is more of looking at medication, seeing what we can change, what we can potentially get rid of, that may be causing more trouble than good."

'You don't feel so alone'

Denise Morrison's husband has been in the program since 2018, when he was not thriving after knee replacement surgery.

She said it's exhausting to be a caregiver, "but when you know that there's a team of people around you, you don't feel so alone." 

The COACH program helped with her husband's mobility, mental health and medication as well as providing respite.  

Without the extra help, said Morrison, "I think without a doubt that we would not be looking after my husband at home; he would be in long-term care." 

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