St. Michael’s Family Health Team Home Visiting Program doubles its capacity to care for frail seniors during the pandemic

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St. Michael’s Family Health Team Home Visiting Program doubles its capacity to care for frail seniors during the pandemic

Toronto, December 21, 2020

By Maria Sarrouh

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Mikey and Penny Lamy. Photo by Yuri Markarov, Medical Media.
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Photo by Yuri Markarov, Medical Media.
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This holiday season, the St. Michael’s Academic Family Health Team’s Home Visiting Program will head out to conduct home visits armed with face masks, face shields, their stethoscopes and a unique tool: boxes of cookies.

The sweet treats are a simple gesture, and also part of a larger plan to keep isolated seniors supported over the holidays.

The stereotype of a house call is a doctor popping by to do a quick blood pressure check on the way home from the office. But the reality is quite different, said Dr. Amy Freedman, a family physician at St. James Town Health Centre. Alongside co-lead Lorna McDougall, Nurse Practitioner for the program, they explain that patients often have multiple illnesses, significant limitations in their mobility and many have dementia. The team focuses on improving quality of life at home and in meeting the wishes and goals of the patient.

“A high proportion of our patients live alone,” Dr. Freedman said. “They’re coping with social isolation and loneliness and the significant impact these problems have on physical and mental health. Studies have shown that loneliness and social isolation have the same impact on health as smoking 15 cigarettes a day.”

“Often, nobody visits them, except for us and their personal support workers,” added McDougall. “Some of our patients have no one in the world. It’s heartbreaking.”

Due to the pandemic, the team took on many new patients to meet the increased demand for home-based primary care.

“Patients weren’t receiving care for their chronic diseases. Many ended up running out of their medications, or becoming weaker, having a fall and getting admitted to hospital,” Dr. Freedman said.

The team does all visits in personal protective equipment. Much like the team from St. Joseph’s Family Health team conducting home visits, the St. Michael’s team has found in-person care a crucial way to protect the frail elderly. Almost none of the St. Michael’s team’s patients have access to technology for video visits and the some don’t even have a telephone, making the need for in-person visits essential.

The number of people getting admitted to long-term care homes has also decreased due to frequent COVID-19 outbreaks. Patients who need admission to a long-term care home are dealing with long waiting lists, whereas some individuals who were interested to be placed in a home before the pandemic have changed their minds due to the high prevalence of COVID-19 in long-term care.

“We’re taking care of our patients longer than we ordinarily would,” said McDougall. “We’re essentially providing long-term care in their home.”

To meet the high demand for home visits, the team recruited Dr. Jessica Cuppage, a Family Physician who is a recent graduate of the Care of the Elderly Enhanced Skills Program in the Department of Family and Community Medicine at the University of Toronto. Dr. Freedman and Dr. Ann Stewart, another St. Michael’s Family Physician on the team, also work with family medicine residents who see patients at home as part of their training.

Patients who don’t have a family physician or can’t access primary care are often referred to the program by acute care hospitals when discharging a patient home or by the Toronto Central Local Health Integration Network (LHIN). Mikey Lamy joined the home visiting program over one year ago after it was recommended to him and his wife Penny by the St. Michael’s Emergency Department.

Like many patients in the program, Mikey suffers from mobility and memory issues. Penny is legally blind and uses a wheelchair. They were unable to visit their family doctor when Mikey began having extreme difficulty walking outside the home.

“It just wasn’t working for us, it was too far away. Mikey couldn’t do it physically or emotionally,” Penny said. “We were panicked about what to do, so having their help is such a relief.”

Penny doesn’t want Mikey to go to a nursing home, and neither does he. The home visiting program gives them their preferred option to remain at home with the right supports and Mikey has felt healthier since he enrolled in the program.

“The visits have cheered me up,” he said. “I have a really great relationship with all the doctors and nurses.”

“We’ve been married for 45 years,” Penny added. “What would he do without all his books? We feel his quality of life is better this way.”

In addition to support from Dr. Freedman and McDougall, Mikey is followed at home by Dr. Maggie Hess, a Family Medicine Resident; and Jennifer Bugera, a Nurse. He also has support from a team of nurses, coordinators and personal support workers from the LHIN. They all work together to help Mikey manage his diabetes, heart condition, memory issues and painful calluses on his feet. In addition, they monitor his heart closely, since he underwent a surgery to have a stent inserted several months ago.

“If they weren’t looking after him, we don’t know how he would be,” said Penny. “When Mikey is sick, they come to our home frequently. They show up for us. We love them.”

Visiting patients in their homes is Dr. Freedman’s favourite part of being a family doctor.

“We love taking care of our patients,” she said. “Going into someone’s home, you get to know them in a way you never would in the sterile environment of an office. It’s very rewarding.”

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in more than 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the Hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael’s Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.

About Unity Health Toronto

Unity Health Toronto, comprised of Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital, works to advance the health of everyone in our urban communities and beyond. Our health network serves patients, residents and clients across the full spectrum of care, spanning primary care, secondary community care, tertiary and quaternary care services to post-acute through rehabilitation, palliative care and long-term care, while investing in world-class research and education. For more information, visit

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