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The doctor is calling: Hamilton physicians band together to call frail older patients during pandemic

When the pandemic began, family physician Dr. Henry Siu expected a surge in phone calls from older patients — not only would they be worried about COVID-19, but many were managing chronic illnesses. Instead, his Hamilton clinic wasn’t hearing much from older adults.

“We realized that some of our older patients thought we were busy, so didn’t call us,” he said. “We didn’t want people to fall through the cracks.”

His colleagues at the McMaster Family Health Team echoed his concerns. Together, they decided to proactively check in with vulnerable older adults.

Between April and June 2020, family physician residents and their physician preceptors contacted more than 650 patients. The team — which is based at two clinical sites and also includes social workers, occupational therapists and physiotherapists — provides care for more than 6,000 patients aged 65 years and older.

“Our resident family physicians were vital in the effort to connect with our older patients in a short time frame. I hope that this experience has taught them what impact they can have as future family physicians,” said Dr. Siu.

The program — dubbed a contact and longitudinal monitoring pathway for frail older adults — received funding through the first round of the COVID-19 Pandemic Response and Impact Grant Program, which is supported by a $5 million contribution from the CMA Foundation.

“This is the epitome of primary care and how family medicine can help the community, keeping us all healthy,” said Dr. Siu.

Patients were identified using the Clinical Frailty Scale, a tool that clinicians use to classify patients’ frailty on a scale of one to nine based on their knowledge of a person’s functional independence and clinical status. Physicians then prioritized and called older adults using their frailty scores. Physicians broached topics including general physical and mental health, COVID-19 risks, financial and food security, prescription renewals and advanced care planning.

“From a primary care perspective, it’s important we keep the health of all of our patients stable, not just those suffering from COVID-19,” said Dr. Siu.

The CMA Foundation contributed $5 million to the Foundation for Advancing Family Medicine (FAFM) COVID-19 Pandemic Response and Impact Grant Program. This program is helping family physicians innovate to provide care during the pandemic.

He noted that COVID-19 has created a backlog in health care, and preventive care will help take pressure off hospitals. The McMaster Family Health Team program has also highlighted the mental health struggles many seniors are facing.

“We thought food and financial security would be the most pressing concerns, but more often people brought up anxiety around the pandemic,” he said.

The next step is a series of focus groups, so family physicians within the team can design tailored support options for frail older adults, including how to combat social isolation.

“This type of project really speaks to the importance of being proactive in our care provision, rather than being reactive,” said Dr. Siu.

About the author(s)

Originally established in 2005, the CMA Foundation is a registered charity, designated as a private foundation, whose sole member is the Canadian Medical Association. Its purpose is to provide impactful charitable giving to registered Canadian charities and qualified donees to further excellence in health care.

Profile Photo of The CMA Foundation staff