Healthcare Quarterly

Healthcare Quarterly 22(1) April 2019 : 30-35.doi:10.12927/hcq.2019.25839
Effective Primary Care

Aging at Home: A Portrait of Home-Based Primary Care across Canada

Sabrina Akhtar, Mayura Loganathan, Mark Nowaczynski, Samir Sinha, Amanda Condon, Vivian Ewa, John C. Kirk and Thuy-Nga Pham


Older adults and their families often struggle in navigating an increasingly fragmented healthcare system when it becomes increasingly difficult to receive care beyond their homes in the face of advanced illness, frailty and complex care needs. The provision of integrated home-based primary care has demonstrated improved patient and caregiver experiences and reduced healthcare costs when primary care providers collaborate in delivering care as part of larger interprofessional teams. In this trans-Canada portrait of five urban home-based primary care programs, their core features are highlighted to provide a roadmap on how to integrate this form of care into a Patient's Medical Home in partnership with acute and home-care providers.

What Is the Landscape of Primary Care for Homebound Older Adults across Canada?

A quarter of Canada's population will be over the age of 65 in the next 15 years (Statistics Canada 2014). Whereas roughly 10% of older Canadians are currently living with frailty (Bibas et al. 2014), around 80% are living with at least one chronic medical condition (Public Health Agency of Canada 2010). Indeed, the combination of an aging population and an increasing prevalence of frailty and multimorbidity will only continue to place increasing strain on hospitals and emergency departments (EDs) in our healthcare system, which never enshrined the provision of home-based and long-term care services as part of our Canada Health Act.

Currently, 93% of Canadians over the age of 65 live in private households, with 100,000 estimated to be permanently homebound (Stall et al. 2013). Although the definition of what it means to be "homebound" varies in the medical literature, there is consistent agreement that it refers to patients with medical, cognitive and/or social frailty whose needs are no longer addressed by office-based medicine. Not surprisingly, older adults who are homebound have higher rates of ED use and double the rate of annual hospitalizations than those who are not homebound (Stall et al. 2013). As a result, for these patients, having access to home-based care is a necessity and not a convenience.

Delivery of home-based care through house calls has historically been part of the role and responsibilities of Canadian family physicians toward their frail elderly patients. With growing patient volumes, an ongoing undersupply of family physicians and a lack of system integration between the delivery of primary, community and acute care, increasing and competing demands on primary care providers have contributed to a decline in the provision of house calls by family physicians (Buchman 2012).

In the US, the growing provision of home-based primary care (HBPC) has demonstrated improved patient and caregiver experiences and outcomes and reduced total healthcare costs for homebound older adults (Totten et al. 2016). HBPC is an interprofessional team-based model of primary care led by a physician or nurse practitioner that further integrates and leverages the support of home and community care services. In this model, comprehensive primary and end-of-life care is delivered to homebound older adults whose needs could not be otherwise met through office- or hospital-based care. Three key design components of HBPC models were identified among nine North American interventions by Stall et al. (2014):

  1. the primary care provider leads an interprofessional care team;
  2. the program holds regular interprofessional care meetings; and
  3. the program provides after-hours support.

Although individual team features might vary, HBPC works to ensure that access to ongoing high-quality primary medical care is provided for homebound older adults that maximizes independence and function, enhances care quality and experience for both patients and their caregivers and reduces ED utilization and hospital admissions. A focused commitment to integration of the provision of primary care with supportive community and home-care services defines Canadian teams who have come to adapt the model to integrated home-based primary care (IHBPC).

Over the past decade, team-based primary care has been introduced and supported to develop across Canada. A strong commitment to the concept of a Patient's Medical Home by the Canadian College of Family Physicians that sets forth a vision for "seamless care, throughout every stage of life, integrated with other health services" (, has further supported primary care physician leadership across Canada to implement IHBPC as one of the core activities of their teams.

In this portrait of five Canadian urban primary care teams that care for homebound older adults across our country, we highlight and examine each program for the core features of team structure and system integration beyond the provision of primary care. From west to east – Calgary, Winnipeg, Toronto and Montreal – this Canadian roadmap of IHBPC will enable us to better serve a growing marginalized population that "can be invisible if we are not looking" for them (Sawchuk 2019, president of the Canadian College of Family Physicians).

The Calgary Integrated Home Care Geriatric Consult Team

The Calgary Integrated Home Care Geriatric Consult Team (HCGCT) was launched in 2013 and provides comprehensive assessments of homebound frail older patients who receive home-care services in the Calgary zone. The team goals are to optimize independent living and improve quality of life. Unlike the other teams presented in this review, this consultant team does not provide continuous, ongoing primary care.

System integration with primary care

The HCGCT completes in-home assessments, formulating diagnoses and treatment plans while collaborating with the primary care provider and the referral source and linking patients with existing community resources. This role aims to facilitate early discharge from hospital to home and reduce acute care utilization. Advance care planning is a core activity, along with working in collaboration with the local palliative care team. A key enabler of success is the participation of the home-care case manager at rounds. This has helped the HCGCT to perform its role as a consultative service within the Patient's Medical Home by maintaining integration with the primary provider.

In 2015, there was a 51% decrease in the number of ED visits by HCGCT clients at six months post referral to the program. There was also a 32% reduction in the number of clients making multiple ED visits in the first three months and a further 13% reduction within six months. Preliminary caregiver surveys further suggest that an improved overall quality of life and satisfaction with the program have been achieved.

Team structure and patient referrals

The team is composed of physiotherapists, occupational therapists, registered nurses, a nurse practitioner, social workers, care of the elderly (COE) physicians and pharmacists. Patient assessments are discussed weekly at team rounds, and a summary of the assessments and recommendations is sent to the family physician. Primary care providers, hospital inpatient teams, community paramedics and the Complex Care Hub (a model of care that provides ongoing acute medical care in the home) can refer their home-living older adults with chronic, complex multimorbidities, dementia, polypharmacy, mobility/falls or frailty concerns to the HCGCT. The program also receives referrals from home-care case managers and the local seniors' referral telephone line.

Winnipeg Regional Health Authority: Hospital Home Team

From 2014 to 2017, the Winnipeg Regional Health Authority funded the Hospital Home Team, a partnership between home care and primary care that focused on patients with complex needs who were frequent users of hospital services. The program had explicit goals of reducing ED visits, length of stay and hospital admissions.

System integration with primary care

Home-care case coordinators were embedded within existing interprofessional primary care teams. Teams worked collaboratively with local community hospitals to support patients in transition from hospital, providing disposition planning support and prompt follow-up upon discharge. The teams provided proactive, planned home visits, as well as after-hours availability by phone. Urgent home visits were also provided whenever possible. Changes within the administrative structure of the provincial healthcare system in 2017 resulted in a discontinuation of the funded partnership between hospitals and primary care, but a smaller IHBPC practice has been maintained within the existing interprofessional primary care teams. Two new programs were created, Rapid Response Nursing and Priority Home, which provide new opportunities for collaboration.

Team structure and patient referrals

Family physicians and primary care nurses provide continuous IHBPC. The team continues to work collaboratively with home-care case coordinators, despite funding cuts to the partnership in 2017. The team meets monthly to review all active patients on the program. New patient referrals to the program occur without a formal process or specific intake criteria, with geography (residing within the local community) being a key criterion. Referrals come from primary care providers or from home-care case coordinators. Prior to the 2017 restructuring, a large number of acute patient referrals came from the hospital.

Toronto House Calls

The catchment area of the House Calls program covers almost half the city of Toronto, with an annual caseload of 600–800, but began as a pilot project in 2007 with one dedicated full-time family physician who had been advocating for years for the needs of his homebound patients (Nowaczynski 2018). Together with a small, part-time interprofessional team donated by a group of not-for-profit agencies, House Calls grew to secure funding in 2009 for a full-time interprofessional primary care team through the Aging at Home Strategy of the Ontario Ministry of Health and Long-Term Care (MOHLTC).

System integration with primary care

Since its founding, House Calls continues to be based in the community in a non-profit community support services agency, Sprint Senior Care, which provides administrative leadership and support, as well as integration with its basket of home support services into the growing caseload of House Calls patients. In 2010, House Calls began a collaborative partnership with the Sinai Health System and University Health Network, Division of Geriatric Medicine, receiving new patient referrals from its EDs, inpatient units and outpatient clinics. A geriatrician provides ongoing geriatric consultations in the home through joint visits with team members as well as acute care advice, thus building a strong collaborative model of primary and specialty care in the home. A study of patients enrolled into House Calls following an index acute care hospitalization showed 53% fewer hospital admissions per year and a 67% annual reduction in days in hospital (Stall et al. 2017).

Team structure and patient referrals

In its first year, House Calls carried a caseload of 80 patients and cared for 135 patients in total. It grew exponentially in subsequent years to a caseload of 350 at any given time while serving 500–600 patients annually with an average age of 88 and with an annual rate of attrition approaching 40%; transfer to long-term care facilities or death were the two main attrition end points. Today, the team has 16 full-time IHBPC team members, including six family physicians, two nurse practitioners, social workers, occupational therapists and team coordinators, to name a few. House Calls has provided clinical placements in all disciplines to hundreds of interprofessional trainees. Referrals come from the highest-needs patients being discharged from hospital or being referred to local home-care services. House Calls is completely dependent on outside referrals of unattached or poorly served patients and offers after-hours care for all of its end-of-life patients.

University of Toronto Department of Family and Community Medicine Academic Family Health Teams

Primary care reform and funding and the introduction of Family Health Teams (FHTs) in Ontario since 2005 have enhanced the ability of local interprofessional clinics to address the needs of those served in the area, including homebound older adults. From 2011 to 2015, the majority of the 14 academic FHTs at the University of Toronto came together with House Calls and the local home-care agency to build a network to improve access to IHBPC for patients across Toronto while simultaneously training future generations of family physicians in the art of IHBPC.

System integration with primary care

A 2011 MOHLTC research innovation grant, BRIDGES (MOHLTC 2013), was a strong system enabler to encourage innovative collaborative projects to emerge between primary, specialty and home-care providers, with a focus on reducing unnecessary hospital visits for the top 5% of patients who use 50% of the healthcare resources in Toronto. Embedding a home-care coordinator into each FHT allows for identification of homebound community-dwelling patients, referrals to the IHBPC teams and timely mobilization of home and community resources prior to hospital discharge.

Team structure and patient referrals

Each of the participating academic FHTs supports between 40 and 100 homebound patients. The majority of patient referrals are identified at home in the community by the embedded FHT home-care coordinators, from the affiliated teaching hospital inpatient or emergency wards, by family physicians on the IHBPC team itself or by local non-hospital-affiliated family physicians. Each Toronto neighbourhood and the homebound patients within are envisioned to be within the catchment area of one of the FHTs or House Calls. Consultant geriatricians or geriatric psychiatrists can be accessed using live videoconferencing, and specialists participate in team rounds, dependent on FHT arrangements. There is close collaboration with the palliative care teams serving Toronto, with some IHBPC teams offering full-scope palliative care as well as after-hours care, including home visits. Ongoing chronic disease management, caregiver support and advance care planning education are strongly enhanced by the physician assistants or nurse practitioners on the teams.

Montreal Herzl Home Care Teaching Program

Created in 2008, Home Care Teaching is one of two programs within the Department of Family Medicine at McGill University. Based at the Herzl Family Practice Centre, a family medicine academic unit within the Jewish General Hospital, the program was developed to train residents to provide comprehensive and continuous medical care to homebound individuals. The success of the program is owing to a supportive administration, a dedicated group of family medicine faculty and, most importantly, the enthusiastic involvement of family medicine trainees.

System integration with primary care

An important component of integration with community services is achieved through doing an environmental home assessment to identify issues such as risk of falls and liaising with the appropriate family and community resources needed to maintain the individual to live safely at home. One of the proactive quality of care initiatives involves educating patients and families about advance care planning and defining goals of care including circumstances that are aligned with treatment at home versus a transfer to the hospital. An important further program expansion has been the Herzl's Family Practice Centre Virtual Ward within the Jewish General Hospital that aims to decrease avoidable hospitalizations with the additional support of a telemedicine program.

Team structure and patient referrals

The program presently provides ongoing HBPC to over 80 patients at any given time. Patients are recruited from the Herzl Family Practice as well as through referrals from community partners. Semi-urgent visits for problems are organized through a weekly resident coverage schedule that is backed up by faculty coverage.

Future Directions for the Provision of Canadian Integrated Home-Based Primary Care

In today's post-reform primary care environment, Canadian family physicians often work in interprofessional teams that focus on population-based health in complex settings that transect primary, acute hospital and home care. This backdrop is similar to that upon which successful HBPC programs operate, described in previous North American studies (Stall et al. 2014). In Canada, the advent of IHBPC has particularly emphasized the key principle of developing models that particularly "integrate" the provision of primary care with supportive community and home-care services.

The IHBPC teams we have highlighted in this article effectively support the health and well-being of Canadian homebound patients living in major urban centres. These teams have emphasized the formation of hospital and/or community partnerships at organizational levels and are often leaders in local system integration projects that target frail, medically complex older adults. The US literature suggests that targeting this population with IHBPC optimizes system cost benefits (Totten et al. 2016). Indeed, the natural and growing expansion of IHBPC models across Canada demonstrates the mounting support for them, which is backed by an ever-growing body of evidence.

Provincial Ministry of Health funding initiatives will be another backbone of support for continued national-scale IHBPC. Although some IHBPC programs have been dismantled through provincial cuts, deliberate new reimbursement models have been implemented in other provinces to encourage greater provision of home-based primary care. In Ontario, the introduction of a Care of the Elderly Alternate Funding Plan in 2012 allowed Ontario primary care physicians wishing to spend 50% or more of their time delivering IHBPC services to be reimbursed under a payment system that recognizes the time to deliver home-based primary care. A more general reimbursement was also introduced subsequently that provides financial threshold bonus payments automatically to family doctors who provide ongoing home-based care. The cumulative effect has led to a growth in both the number of Ontario family physicians providing house calls and patients being served with IHBPC.

With a growing interest in the provision of IHBPC across Canada among both family doctors as well as provincial Ministries of Health, this survey of the evolving models that have appeared across Canada may help to encourage others to further develop this area of care. In the US, the provision of IHBPC has become more mainstream in terms of practice and policy. This is further supported by the establishment of the American Academy of Home Care Medicine ( to support professional development and the advancement of policy relevant to this field of primary care.

Indeed, a similar national advocacy and educational resource group in Canada could serve to promote and protect the art, science and practice of home-based primary care in the continuously evolving landscape of Canadian healthcare. With home care becoming one of the most rapidly expanding areas of medicine both north and south of the 49th parallel, we think Canada is ready for the inception of a Canadian Academy of Home Care Medicine to champion the growth of IHBPC as one of the most cost-effective and compassionate forms of healthcare, which could be essential toward caring for our rapidly aging population as well.


In this portrait of primary care teams that look after frail, homebound patients across Canada's urban centres, we showcase commonalities despite contextual differences across provincial jurisdictions. The teams are primary care based, except for one interprofessional group, and team meetings are critical to coordinate plans across different care sectors and transitions. When formal system infrastructure with local hospitals and home-care agencies is actively enabled, homebound patients can be transitioned between acute care and home successfully and, in many cases, avoid acute care use. A national home-based primary care organization would serve to bolster the ongoing development and scale-up of IHBPC across and within existing primary and community care models.

About the Author

Sabrina Akhtar, MD, MHSc, CCFP, is the physician lead of the Home-Based Care Program (HBCP), UHN Toronto Western Family Health Team, and an assistant professor at the Department of Family and Community Medicine, University of Toronto, Toronto, ON.

Mayura Loganathan, MD, CCFP, is a clinical lecturer, Department of Family and Community Medicine, and physician lead for the Mount Sinai Academic Family Health Team home-visit program, HIPS.

Mark Nowaczynski, PhD, MD, CCFP, FCFP, is the clinical director of House Calls: Interdisciplinary healthcare for homebound seniors, SPRINT Senior Care, and an assistant professor in the Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON.

Samir Sinha, MD, DPhil, FRCPC, AGSF, is the director of Geriatrics at the Sinai Health System and University Health Network in Toronto, ON, and associate professor in the Departments of Medicine, Family and Community Medicine, Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.

Amanda Condon, MD, CCFP, is a family physician practising at ACCESS River East, an interprofessional, community primary care clinic in Winnipeg, MB.

Vivian Ewa, MBBS, CCFP (COE), FCFP, MMedEd, FRCP Edin, is the section chief for Seniors Care and clinical assistant professor in the Department of Family Medicine at the University of Calgary, Calgary, AB. She is also medical director at Facility Living, Alberta Health Services.

John C. Kirk, MD, CCFP (COE), FCFP, is an associate professor in the Department of Family Practice, Faculty of Medicine, McGill University, and the director of the Herzl Family Practice Centre Home Care Teaching Program at the Jewish General Hospital, Montreal, QC.

Thuy-Nga Pham, MD, CCFP, MSc, is an assistant professor, in the Department of Family and Community Medicine at the University of Toronto and the lead physician of the South East Toronto Family Health Team.


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