SEED client Edith Endrenyi (left) with link worker Sandesh Basnet (right).

On a sunny fall day in Toronto, Sandesh Basnet is in the St. Lawrence neighbourhood for a meet-up. The bubbly, young, Nepali-Canadian knocks on the door and is greeted by a surprising companion: Edith Endrenyi, a stoic, 95-year-old Hungarian-Canadian woman who welcomes him into her home for the friendly visit.

The unlikely duo don’t have overlapping circles nor are they neighbours; Basnet is Endrenyi’s link worker through Support, Equity, Engagement and Dignity—or SEED—a new program at St. Michael’s Hospital that received $2.1 million in donor funding last year to launch and support the program for five years.

Developed by St. Michael’s Hospital’s Academic Family Health Team (SMHAFHT), SEED uses social prescribing—an approach to care that attends to social needs rather than medical—to address social isolation among lonely and often marginalized older adults.

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“We’ve been at the forefront of developing programs for social interventions for decades,” says Dr. Gary Bloch, a family physician at St. Michael’s and the medical leader of SEED. “These programs are deeply embedded in our team and were developed ad hoc. But with this funding, we’ve been able to start SEED and really address the social needs of the older adults in our catchment area.”

Nearly 30 per cent of seniors in Canada are at risk of social isolation, an issue that can lead to further consequences including increased risk of falls, reduced quality of life, and premature death.

To help prevent these outcomes, any health-care provider at SMHAFHT can refer their 55+ patients to SEED—patients like Endrenyi, who was referred by her family doctor.

“About seven years ago, my husband died,” says Endrenyi. At her advanced age, many of her friends have passed as well. “I have nobody. I am alone.”

“You have a link worker!” interjects Basnet, forcing her to laugh and agree.

How SEED works

When patients like Endrenyiare are referred to SEED, they begin by meeting with one of the two link workers, Basnet or Murshida Samsun Mueen.

During that initial meeting and in the meetings that follow, the link workers get to know the clients, help to determine what their social needs are, and connect them to resources and programs that help meet those needs.

In the short time that SEED has been active, Basnet and Samsun Mueen have helped clients with a wide variety of interventions, from bringing clients to seniors programs so they can make new friends, to teaching them how to use a smartphone so they can connect with their loved ones more easily, to getting them cleaning services, to helping low-income seniors access affordable food, to simply joining them for a regularly-scheduled coffee.

“I feel like understanding people is like solving a puzzle,” says Basnet, talking about how he figures out what interventions a client needs. “You have to listen to them and what they’re dealing with. Then you have to connect all the dots.”

He recalls one client who barely left her house when he first met her. After getting to know her, Basnet learned that she loved art, so he decided to accompany her to a jewelry-making class at a local seniors’ centre. She was apprehensive at first, but after having so much fun making bracelets—including one for Basnet—the client gained the confidence to go to the seniors’ centre regularly on her own.

When clients meet their link worker for the first time, they often express that they’re depressed and don’t have many plans to look forward to. Samsun Mueen says changing that is one of the best parts of her job.

“When you see the smile and they tell you that they’re looking forward to seeing you next time, it’s very rewarding,” says Samsun Mueen.

“It has been very beautiful so far,” agrees Basnet.

SEED and community engagement

In addition to the work being done by the link workers, the SEED team has a community health worker, Orit Adose, who is building relationships with services in the local community. She is working on building an asset map that shows where clients can access nearby programs and resources. From libraries to ethnic cooking classes to exercise programs, the map will help link workers and clients to find services that fit their personal interests.

This tool, along with how the SEED program functions and what it will turn into, are guided by older adults in the community who are regularly welcomed to share candidly about their social needs.

Nassim Vahidi-Williams, the manager of community engagement for SEED, says it’s so important that the team “engages in community spaces to share the story of what we do and to hear the stories of what the community feels is needed.”

Amplifying community voices helps clients know that their opinions matter and helps the SEED team ensure programming is centred on those they are serving.

The vision for SEED

In the less than a year since SEED has been up and running, 96 clients have been referred to the program, and demand is not slowing down.

Bloch says the SMHAFHT serves 17,000 elderly patients who would benefit from programs like SEED. He hopes the program will grow so more of them can be supported. Further, the SEED team also plans to expand to accept community members who are not SMHAFHT patients.

In the meantime, clients like Endrenyiare enjoying their time with the link workers and the resources they’ve been connected with.

Looking at Basnet warmly, Endrenyisays, “You are an interesting figure for me. When you are here, it’s good.”

This project receives philanthropic funding from Waltons Trust and other anonymous donors.

By: Kaitlin Jingco

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