Home-based health program offers lifeline to local families

Every time Jeannette Valdez took her 94-year-old mother, Carolina, to a medical appointment, it was a struggle.

As Carolina’s sole caregiver, Jeannette often had to arrange transportation and hire a support worker just to get through the outing. “When I took her to the hospital for an appointment, it was in an ambulance, not a car, because one time she almost fell,” Jeannette says. “It was always a big challenge.”

After several hospital admissions at Markham Stouffville Hospital (MSH) for issues related to congestive heart failure, a care coordinator with Ontario Health atHome suggested a referral to the Seniors Home Support (SHS) program, which would connect her with an comprehensive primary care team to support her medical needs at home and help coordinate her ongoing care.

SHS is an integrated primary care program delivered by an interdisciplinary team to home-bound seniors who cannot access office-based primary care services. The care team includes primary care physicians, registered nurses, an occupational therapist, a chiropodist, a pharmacist, community paramedics, and a community care coordinator liaison.

“We deliver timely, comprehensive care to our patients,” says Dr. Annie Cheung, a Primary Care Physician who provides care to SHS patients in Markham and Stouffville. “We also try to help patients and their caregivers navigate the health care system, while addressing their complex needs.”

For Jeannette and Carolina, SHS was transformative. “I’m alone, I’m her nurse, her caregiver, her daughter, everything,” Jeanette says. In addition to receiving help from a personal support worker, SHS home visits gave her time to take care of herself. “That helped me go out and do my grocery shopping and do my errands and everything. It helped me with my sanity. Other people may not understand, but for me to go out and see other people and do what I have to do, it’s a huge help. It helped me be a better caregiver.”

SHS is the first home-based primary care program of its kind in Ontario. It delivers services through home visits, phone calls, and virtual consultations, all coordinated through a single electronic medical record. This seamless access ensures that providers stay informed and patients don’t have to repeat their medical history.

When an SHS-enrolled patient is hospitalized, the team notifies the hospital that they are being followed by a primary care physician and the SHS team. As discharge approaches, the hospital notifies SHS to help anticipate the discharge and coordinate post-hospital care. Many initial referrals to SHS also come from the hospital discharge process.

“My role is to facilitate safe and timely patient discharges, with a strong focus on addressing the ongoing needs of our senior population,” says Sudeep Nair, Patient Flow Coordinator. “Programs like SHS align seamlessly with OVH’s vision of integrated care for healthier communities. It offers high-quality care in patients’ own homes, reducing unnecessary hospital readmissions and enhancing patient outcomes.”

SHS is delivered by partners in Eastern York Region North Durham (EYRND) Ontario Health Team (OHT). Oak Valley Health (OVH) is the largest partner in the EYRND OHT, which connects partners across multiple sectors to develop an integrated system that connects care for patients, families and caregivers in Markham, Stouffville, Thornhill, Brock, and Uxbridge.

EYRND OHT partners providing SHS services are OVH, Markham Family Health Team, York Region Paramedic Services Community Paramedic Program, and Ontario Health atHome. Other EYRND OHT programs include Community Health Clinics in Stouffville and Uxbridge, as well as the Virtual Urgent Care Clinic.

“This model of care is essential as we move toward more integrated and patient-centred care,” says Crystelle Burdeos, a Nurse Navigator with SHS. “As the population ages and health care needs become more complex, collaboration is really important.”

Patients and caregivers appreciate the SHS support, says Burdeos, adding that “families often express a sense of relief and gratitude. They feel reassured, knowing that care is well-organized, with a team working alongside them to support their loved one’s health and coordinate care as needs change.”

Jeannette agrees. She and her mother, who passed away in early 2025, were deeply grateful for SHS. “The doctors and nurses were very helpful,” she says. “I am so deeply grateful for everything the team has given us.”

Photo: Jeannette Valdez was the sole caregiver for her 94-year-old mother.