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Wait At Home

Left to right:  Mississauga Halton CCAC hospital care coordinator Betty visits with Maria at her new residence – a long-term care home in Mississauga.

 

Eighty-five-year-old Maria Daponte has a myriad of health conditions, including congestive heart failure, kidney disease, diabetes, depression, anxiety, high blood pressure, degenerative disc disease, arthritis, reduced mobility, mild cognition and thyroid issues.

Since the passing of her husband 16 years ago, Maria has lived with her daughter's family. However, it became more and more difficult for Maria to get around and she was falling more. Falls are one of the most significant risks to older adults, and a major fall can lead to hospitalization. This is what happened to Maria; she fell in the middle of the night and could not get up. Her family called 911 and Maria went to the hospital where she remained for several months.

Mississauga Halton CCAC hospital care coordinator Betty Vieira who works at Trillium Health Partners' Credit Valley Hospital location met with Maria and her family to assess Maria's health care needs.  A Registered Nurse with more than 20 years' experience, including hospitals and long-term care, Betty directly interacts with members of the multidisciplinary hospital team. While Maria was in hospital, Betty discussed the Home First options (Mississauga Halton CCAC's Wait at Home program is one of the services under this umbrella). Betty also provided information about long-term care and community supports.

Seniors such as Maria are assessed to that Betty can design a personalized care plan and services for a limited amount of time so that Maria can return home safely and then decide where  she wants to live long-term. The Wait at Home program enables patients to make this potentially life-altering decision over time and in a familiar setting, rather than in a stressful hospital environment.

Upon her return home, a Mississauga Halton CCAC community care coordinator visited Maria to conduct a health assessment. The Care Coordinator revised Maria's care plan and discussed Maria's health needs and concerns with her.  Maria was finding it difficult to live at home. She used love going to an adult day program, but it was increasingly difficult for her to get out because of her numerous health issues.

Maria decided that she would like to move to a long-term care home because of her failing health. Also, she had taken care of her elderly parents and did not want to be a burden on her daughter's family.

Maria's community care coordinator walked Maria's family through the long-term application process and helped them complete the necessary paperwork.

Three weeks after returning home from the hospital, Maria received a placement offer from her first choice of homes. Maria has settled into her new home; she participates in the daily activities and has found new friends. She is most appreciative of the care she received from her Mississauga Halton CCAC care team.

The path to long-term care is unique for every patient. Many seniors can live safely and comfortably at home, with the proper supports, and never enter long-term care. For others, the progression of illness or disability triggers the difficult decision to apply for long-term care, which is the decision that Maria made.

Fatima Daponte-Conway, Maria's daughter, shares her experience with the Mississauga Halton CCAC, "I had a very positive experience. My mother has been receiving care from the Mississauga Halton CCAC for a number of years.  She has settled into the long-term care home and is thriving."