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
The Health TAPESTRY intervention is based
on four main parts:
- interprofessional primary healthcare teams that provide health care services to the Health TAPESTRY
client and work with them on meeting their goals,
- trained community volunteers that
connect with clients in their home to gather health and social information and
to discuss life and health goals,
- 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,
- 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
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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
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
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
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 “
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
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
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
“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
“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,
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
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