Her passion, however, is making art, and in her kitchen hangs her favourite creation — a large canvas with swirls of bright colours, as if rainbows are being sucked into a vortex.
“This is the painting I truly love,” says James. “When I did this I was so happy, you have no idea.” She still is: “I’m 79 and it’s thrilling.”
But her body is breaking down. Her bones are brittle from osteoporosis, her blood pressure is high, her chest aches, and, sometimes, she sees double.
In January, she injured her spine and could no longer get out of bed. Frustrating weeks of trying to get appropriate medical care ended when she found Dr. Sabrina Akhtar, a young family physician who makes house calls.
Akhtar is the founder of a fledging project for homebound seniors at Toronto Western Hospital. Supported by a small team of nurses, dietitians and social workers, she spends three afternoons a week visiting patients like James.
Since March, Akhtar has discovered that James also has high cholesterol and shows signs of perhaps having suffered a mini-stroke. She got James a hospital bed for her Junction Triangle home, a walker, a high toilet seat, cholesterol pills, heart medication and an appointment with a cardiologist.
“You have no idea how much of a relief this is for me and my family,” James says, referring to house calls from Akhtar and her team. “If I hadn’t found out about them I’d still be lying in bed.”
James’s good fortune is rare in Ontario. But the provincial Liberal government promised this week to spread it to many others.
“House calls are coming back to Ontario, so anyone who has difficulty getting to appointments will be cared for right in their homes,” said health minister Deb Matthews.
She promised to spend $60 million annually to make it happen — if the Liberal government is re-elected in October.
Matthews gave few details of how the money would be spent. And opposition parties questioned the government’s commitment, noting that thousands are already on waiting lists for home care in the province.
What no one disputes is the need for many more house calls, particularly with Canada’s rapidly aging population. In interviews, the presidents of both the Ontario Medical Association and the College of Family Physicians of Canada applauded the Liberal promise.
It used to be that house calls were a normal part of a family doctor’s practice. In the 1930s, 40 per cent of all patient-doctor interactions in Canada occurred in the patient’s home, according to house call specialist Dr. Mark Nowaczynski, an assistant professor of medicine at the University of Toronto.
Patients back then often suffered from infectious diseases, and doctors didn’t want them spreading germs in their waiting rooms. The widespread use of antibiotics eventually lowered the need for these kinds of house calls, says Nowaczynski, who leads a unique team of caregivers doing nothing but house calls to homebound seniors in North Toronto.
As the population has aged, doctors face patients with an array of ailments which made office visits longer, increased paperwork, and required the use of equipment that couldn’t be lugged to homes.
Medicare’s billing system has also encouraged sedentary practices. OHIP pays doctors for every patient they see, and doctors can see more patients, and make more money, sitting in their office than driving to house calls.
OHIP pays $65 for a house call, $106 if it’s in the evening. The day rate is about twice as much as for an office consultation.
In the 1980s, doctors for whom house calls made up more than 50 per cent of billings saw rates for such visits slashed. OHIP wanted to prevent physicians from working solely out of their cars, racking up house calls for common colds or one-time medical episodes without providing continuity of care.
In the early 1990s, the threshold was lowered from 50 to 20 per cent. Not surprisingly, house calls dwindled.
The threshold is now gone, but so is the medical culture of house calls, Nowaczynski says. Few medical students or physician residents are exposed to the practice in their training.
In surveys by the College of Family Physicians of Canada, the number of family doctors who say they “offer” house call services dropped from 48 per cent in 2007 to 42 per cent in 2010. In Ontario, it went from 51 to 46 per cent. Only 1.4 per cent in Ontario described house calls as a “specific area of focus” in their practice.
In 2010, the number of home visits billed by Ontario physicians was 484,600. The number of office visits billed in 2004 was reported as 43 million. (The ministry of health did not provide an updated figure.)
There is at least one service in the GTA that provides same-day house calls for non-emergency care to anyone who calls. But neither the College of Family Physicians nor the OMA want house calls to be a medical model for people who are mobile.
Experts say the key component to any effective house-call program is continuity of care. That’s when patients and health-care budgets benefit most.
Nowaczynski’s team of five people, including a nurse, a social worker and an occupational therapist, make regular house calls to 250 homebound seniors. His not-for-profit program, House Calls, operates with a $480,000 a year grant from the province. He says his team is the only one in Toronto that exclusively provides on-going, integrated care to frail seniors. (There are programs, including one at Mount Sinai Hospital, that make house calls to palliative-care patients.)
The health minister consulted Nowaczynski about her proposal and made the announcement at the Toronto home of one of his patients, 83-year-old Barbara Burns.
Without his team’s care, Nowaczynski says, Burns would have spent the past three years in a long-term care facility, at a cost to the government of $50,000 a year. The team has also treated flare-ups of her chronic conditions, avoiding at least three expensive hospital admissions. He estimates his team’s care for Burns has so far cost $6,000, and saved the health budget $200,000.
“If we don’t look at better ways of delivering care to those seniors who aren’t being well-served by the current system, we will inevitably choke up our hospitals with people who have had multiple problems neglected for so long that you’re now left with a mess to deal with,” Nowaczynski says.
What can’t be calculated is the relief that on-going house calls bring to people like Heather James.
“Since she’s been getting this care, it’s been fantastic,” says her son Jamie, 58, who plays guitar in actor Dennis Quaid’s rock and blues band, and was visiting from Los Angeles this week. “We go for walks around the block — we were at Starbucks the other day, and she hadn’t been there in 11 months.”
James lives on the ground floor of a house whose walls are covered with her artwork. In her living room is a dollhouse, a framed photograph of her father in his RCMP uniform, and an open birdcage with Bella, a blue budgie that flies around the room.
The hospital bed is in what would normally be the dining room. A two-foot high statue of an angel looks down on it from a shelf.
“I’m one of those people who believe in angels,” says James, who has four adult children and five grandchildren. “I’ve already ordered my specific wings — I have.”
James’ mind is sharp and her eyes sparkle. But her body isn’t keeping up. She’s fallen twice and once broke her shoulder.
She notes that many seniors are incapable of making the effort and phone calls it took her to get the care she needed. A worker at a Community Care Access Centre eventually put her in touch with Akhtar, who luckily had one spot left in her 30-patient homebound project.
Akhtar’s commitment to home care was fueled by residency work with Nowaczynski. She’s having trouble attracting other doctors to her project because she says the Health Ministry doesn’t allow physicians on Family Health Teams — set up by the province in 2005 — to access the higher OHIP fees for house calls.
So Akhtar enlists the help of resident physicians such as Dr. Annie Doan, who accompanied her on James’s half-hour home visit last week.
James complained that she suddenly found herself short of breath and listing to the left when she took a few steps. The doctors monitored her blood pressure, breathing and eyes, and tested the strength in her arms and legs.
Akhtar then explained the artery-clogging effects of cholesterol — a condition James had never heard of — and reminded her to pick up pills for it that afternoon, urging her to overcome her reluctance to pop them. She then mentioned the “worst case scenario” of a light stroke and confirmed James’ appointment with a cardiologist.
“If the chest (pain) gets worse, if the walking funny gets worse . . . just call us,” Akhtar said, adding that a nurse would be coming once a week to monitor James’s blood pressure.
“It’s imperative we have more programs like this — especially for seniors,” James says. “It is so easy for us to be brushed off or forgotten.”
Source http://www.thestar.com/
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