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The following opinion article co-written by NOHT-ÉSON Executive Director Sabrina Piluso and Niagara Health President and Chief Executive Officer Lynn Guerriero appeared in the December 2 print and online editions of the Niagara Falls Review, St. Catharines Standard, and Welland Tribune:

It takes a region to keep Niagara healthy

Just as it takes a village to raise a child, it takes an entire region working together to keep Niagara residents healthy and supported at every stage of life. From family doctors and pharmacists to home care providers, hospitals, social services and long-term care facilities, every part of the system has a role in ensuring healthcare works effectively.

Niagara’s healthcare challenges are significant. Our population is not only aging but also growing and becoming more diverse, which brings new complexities to the care we provide. Rates of chronic illnesses, such as diabetes and heart disease, are higher than the provincial average. At the same time, we face a shortage of family doctors, specialists and home care services. These pressures are compounded by healthcare workforce challenges, with many professionals experiencing burnout, leaving healthcare altogether, or unable to participate to their full capacity due to increasing family and social demands.

No single organization can tackle these challenges alone. The most meaningful progress happens when every part of the system works together to ensure patients receive the right care in the right place at the right time.

Imagine an older adult in Niagara living with diabetes. They begin noticing small changes in their health but face barriers accessing a family doctor. Instead of heading straight to the Emergency Department (ED), they turn to other options. Perhaps they speak with their pharmacist, who provides expert advice, helps them understand their medications, and points them to one of the many Diabetes Education Programs in Niagara. Or they connect with an Ontario Health @Home care coordinator, receiving support where they’re most comfortable — at home. These are just two examples of how our healthcare system can collaborate to guide people to the right care at the right time.

Niagara Health is working hard to make collaboration a reality. Programs like SCOPE Niagara connect family doctors with hospital specialists in real-time, helping to manage complex cases and prevent unnecessary hospital visits. The Geriatric Assessment Program conducts a comprehensive physical and cognitive assessment that helps older adults maintain their health and independence, reducing avoidable hospitalizations. Social workers in EDs connect patients with community services before hospital admission becomes the default, while ED techs — trained paramedics — help limit ambulance off-load delays, ensuring timely care and freeing up emergency responders.

We know hospitals can’t do it all. Consider alternate level of care (ALC) patients — individuals who no longer require hospital care but remain admitted due to a shortage of community supports. This creates a ripple effect: EDs back up, ambulance off-load delays increase, and patients needing acute care wait longer. Solving this requires collaboration across the entire system, from home care to long-term care and community services.

St. Catharines, ON – Niagara residents with a chronic illness and their care partners can access a specially trained registered nurse to assist them in managing their symptoms and day-to-day well-being in the comfort of their homes.

The Virtual Care Monitoring (VCM) program, a Hospice Niagara-led initiative of the NOHT-ÉSON, enables patients to report their symptoms through a weekly health questionnaire. A registered nurse then reviews the questionnaire and contacts the person for more details if necessary. The nurse can also reach out to the patient’s doctor, family or connect them to community services that can best support the person’s needs.

“Whether it is cancer, chronic obstructive pulmonary disease (COPD) or another progressive, life-limiting illness, we know that a palliative approach to care early in a person’s illness or when transitioning home from hospital can improve health outcomes and quality of life for themselves and their loved ones,” said Sue Shipley, Senior Director of Clinical Services at Hospice Niagara.

“The Virtual Care Monitoring program also means that the patient has a dedicated registered nurse on their team who can respond to the person’s symptoms before a crisis occurs. Depending on the issue, the nurse can support the person with a phone call and the most appropriate health care resource, including their doctor or primary care team.”

Some of the program’s benefits include the patient’s increased engagement in their own health care journey, greater access to health care resources, and potential avoidance of emergency department visits.

Through the program, a tablet is provided to the person to use in their home, or they can use their own mobile device. There is also support to set up and use the virtual care monitoring technology. The program is offered at no cost.

“The registered nurse’s knowledge and medical expertise to assist and guide me through the navigation of the health care system has proven invaluable,” said Andrea Atack, whose father, James, frequently visited the hospital for symptoms associated with congestive heart failure before he enrolled in the program.

“The nurse monitors my dad’s situation closely and keeps in touch with my father and me, and our family doctor is contacted if medication needs to be adjusted or a call or visit is needed. To my dad and I, this is one of the program’s greatest benefits.”

Primary care teams and physicians can refer their patients to the VCM program, or the person can self-refer by visiting www.hospiceniagara.ca/virtual-care-monitoring or calling 289-969-7307.