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Health TAPESTRY is a novel and proactive approach that helps people stay healthier for longer in the places where they live by bringing together interprofessional health care teams, trained volunteers, community engagement, and technology. Health TAPESTRY is identifying people at risk before they need invasive and expensive interventions, like going to a hospital.

The Health TAPESTRY intervention is based on four main parts:

1. interprofessional primary healthcare teams that provide health care services to the Health TAPESTRY client and work with them on meeting their goals,
2. trained community volunteers that connect with clients in their home to gather health and social information and to discuss life and health goals,
3. community engagement and connections that helps the Health TAPESTRY approach fit to the changing needs of a community by learning from the community and forming partnerships with other organizations, and
4. the use of technology that connects clients, their health care team, volunteers and the community.

The four parts of Health TAPESTRY each play a role in system navigation which helps clients understand and access a strong network of community organizations, including their primary care team, as part of their health care. Learn more about Health TAPESTRY here.

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The Health TAPESTRY approach has been pilot tested with older adults, rural residents, First Nations individuals, and new immigrants in Ontario, British Columbia, Alberta, Saskatchewan, Québec, and Newfoundland and Labrador with very positive results.

In 2017, the McMaster University Department of Family Medicine began Health TAPESTRY Ontario, a $3 million project, generously funded by the Ontario Ministry of Health and Long-Term Care and David Braley. This project brought Health TAPESTRY to six primary care sites across Ontario, including Dufferin Area Family Health Team (DAFHT).

In 2018, DAFHT, McMaster Family Medicine, and Canadian Red Cross entered a partnership to become an implementation site.

Ontario Health (Quality Division) had a chance to catch up with Lianne Barbour, Executive Director and Heidi Vanderhorst, Program Manager at DAFHT to learn how this approach is being implemented at their site, and the results they have achieved.

How is the Health TAPESTRY approach being implemented at DAFHT?

At DAFHT, the Health TAPESTRY approach is being used to identify clients 70 years of age and older that are currently not considered complex but may benefit from early identification of their health care needs to prevent hospital admissions and emergency department visits.

Initially Dr. Douglas Oliver from the McMaster University research team met with the DAFHT physicians. An Electronic Medical Record (EMR) query was run to identify potential clients to participate and the physicians reviewed the list for appropriateness.

Once clients consent to participate, Canadian Red Cross volunteers visit them in their home. The visits involve two volunteers and are around 90 minutes. They use a tablet and the “ TAP-App” to jointly create a detailed electronic summary of the client’s goals of care. The summary is sent electronically from the volunteers’ tablet to the FHT.

The DAFHT Health TAPESTRY team meets biweekly to discuss client reports and identify ones that may benefit from further support from DAFHT providers and other community resources. The team huddle includes the physician (dependent on availability), nurse educator, occupational therapist, registered dietitian, social worker, and the Canadian Red Cross coordinator.

What results have you seen so far?

To date, 136 clients have been enrolled and have had visits from the Canadian Red Cross volunteers. Each client’s summary was shared in at least one huddle with the DAFHT Health TAPESTRY Team.

The nurse educator conducts telephone follow-up with clients based on the teams’ recommendations. Referrals include home safety visits with the occupational therapist, visits with the dietitian, and many clients wanting to work on Advanced Care Planning. Over 80 allied health visits have been generated.

DAFHT is currently part of a larger research evaluation that includes provider satisfaction and team functioning. Findings will be published in the fall of 2020.

Can you tell us more about the Canadian Red Cross volunteers you work with?

Many of the volunteers are students in health and/or community services programs at the local college. Some volunteers are previous recipients of the program and felt this was a valuable way to contribute to their community.

Two volunteers share their experiences:

"Being able to immerse myself in holistic, patient-involved care has changed my outlook and sense of community. I’m able to engage in challenging conversations that open my eyes and improve my learning. Health TAPESTRY, with the intention of keeping the aging population at home for as long as possible; creates and tailors care specific to the individual’s needs ensuring that the client and health team are connected to each other, the community, and its resources via a community connector volunteer such as myself."

Adriana, Health TAPESTRY Dufferin Volunteer, Nursing Student

“If I could capture the essence of what Health TAPESTRY means to our clients in two words, it would be recognition and hope. Recognizing clients brings hope for a better future with regards to health, self-esteem and socialization.”

Cheryl, Health TAPESTRY Dufferin Volunteer, Retired Public Health Professional

What enables this approach to succeed?

One of the most crucial features is “physician buy-in”. The project began with the McMaster University research physicians meeting with the FHT physicians involved in the project. This increased physician engagement tremendously.

“Tapestry has opened a window into aspects of my patients' life that I don’t get to see in an office setting. It is humbling to remind myself that, even though I spend time with my patients, I might have key information missing from their past, not necessarily medically relevant information but definitely part of the story that helps me understand who my patients are as wholesome human beings -- this has now strengthened my physician/patient relationships going forward.”

Dr. Mercedes Rodriguez, Physician Lead

The project would not be possible without the volunteers. The volunteer coordinator recruits, coordinates, trains and provides ongoing support. The volunteers are very engaged and are a backbone for the program. Building relationships with local community supports is very important so that clients can get the ongoing support they need to prevent disease, remain at home, and avoid hospitalization.

We are looking forward to getting the results from the evaluation to understand how and where this intervention works best. The pilot at DAFHT is still underway and has funding until August 2020. A sustainable funding model will be needed before this approach can be spread.

To learn more, interested primary care organizations can get in touch with McMaster University.