Glace Bay senior gains strength and confidence with help from Nova Scotia Health’s Seniors’ Care Team

Earlier this year, 88-year-old Sylvia Clements of Glace Bay wasn’t feeling well and was experiencing confusion. She had recently been diagnosed with early-stage dementia, so her family took her to the emergency department at Cape Breton Regional Hospital (CBRH) in Sydney.

When Sylvia arrived, she was screened by the Seniors’ Care Team, and it was determined she would benefit from their services and support. A collaborative care plan was developed with Sylvia to support her return to the place she calls home and avoid hospital admission. After she returned home, the team followed Sylvia to ensure she was managing well.

Introduced about a year ago as a pilot at four regional hospitals, including CBRH, Seniors’ Care Teams support adults 65 years and older to prevent avoidable hospital admissions and provide assistance in accessing community supports, equipment and services—ensuring continuity of care and improving patient outcomes. The team may include a nurse, care co-ordinator from Continuing Care, occupational therapist, physiotherapist, pharmacist, exercise physiologist, recreation therapist or social worker.

Nova Scotia Health and the Seniors Care Teams embrace a “home first” philosophy, recognizing that people often recover faster at home, where they are in a familiar place and routines. Being around family and loved ones and having access to community support can enhance physical and emotional recovery and foster independence.

For Maureen Clements, Sylvia’s daughter-in-law and primary caregiver, her first interaction with the Seniors’ Care Team left a lasting impression.  “They were wonderful,” said Maureen. “They were very knowledgeable, friendly, patient and knew what they were doing.”

The Seniors’ Care Team added another layer of support by helping Sylvia and her family better manage her health and maintain her independence at home. One of the things that stood out most was how well the team worked together. “We liked the fact that they communicated with each other,” said Maureen. “Everybody was on the same page.”

That co-ordinated approach led to positive changes for Sylvia. For example, after reviewing her medications, the Seniors’ Care Team pharmacist made changes. “Adjusting her medication made a big difference,” said Maureen. “Sylvia isn’t nearly as confused.”

Since this model was introduced at CBRH as a pilot in November 2025, the team has assessed 479 patients and completed 760 home visits as of the end of September. Across the province, Seniors’ Care Teams have assessed 2,056 patients and conducted 1,331 home visits.

James Buick, an exercise physiologist from the Seniors’ Care Team, visited Sylvia at home and, after assessing her abilities, developed a personalized exercise program designed to build Sylvia’s confidence and improve her strength and mobility.

“Sometimes exercise starts with simple movements, such as standing up from a chair, sitting back down or raising your heels off the floor,” said Buick. “While these activities may seem small, they can have a big impact on a person's strength, balance and overall health,” he said. "Our goal as a team is to help people not only to stay at home, but to thrive."

From Maureen’s perspective, the benefits for Sylvia have gone beyond physical health; it has improved her confidence and outlook. “Her mobility has improved, and she feels better about herself.” Although Sylvia uses a walker, she is becoming more active and is even considering taking short walks down the driveway.

For Maureen, the greatest benefit has been knowing they are not facing these challenges alone. “The comfort of knowing that there are people who really care and are willing and able to help,” she said. “It takes a load off my shoulders and the family.”

Sylvia’s story highlights the value of the Seniors Care Team’s intervention in coordinating the right support. By helping her avoid hospitalization, the team enabled a recovery journey that improved her health, strengthened her confidence and helped her to heal at home.

Photo of (L-R): Maureen and Sylvia Clements.