Outcomes Mattered For Robert

Robert (first name used with permission) was 54 when his doctor referred him to the Centre For Aging and Brain Health Innovation (CABHI) for participation in a partnered study with UNB and Loch Lomond Villa. This study was a usability and feasibility study for using technology in the home to support healthy aging in place.

Robert suffered (and still suffers) from a cognitive impairment which presents significant safety concerns related to non-medication compliance. He also suffers from severe back pain. Due to his cognitive impairment, he demonstrated an inability to consistently adhere to prescribed doses resulting in missed doses and potential overuse. Other environmental issues contributed to Robert’s instability…neighbours stealing his medications and inappropriate caregiver support. He lacked structure and proper oversight to safely manage his complex needs.

As a result, Robert’s back pain was poorly managed, contributing to functional decline, increased risk of falls and a diminished quality of life. Ambulance calls were frequent.

His physician recognized that Robert’s condition needed a more complex response than traditional primary care model could offer and referred him to the CABHI study.

In 2018, Robert began to successfully live independently at home with the support of a comprehensive supportive care model. The service provided him with 24/7 support using, primarily, technological intervention and nursing oversight.

The service provided him with:

-            Remote monitoring attached to a nurse. It helped monitor his medication consumption with frequent virtual wellness and safety check-ins.

-            A daily review of his health data.

-            Weekly health team / family member meeting which could include his pharmacist and/or home care worker.

-            Daily medication witnessing to ensure safety.

-            Secure messaging with priority response.

-            Ongoing care plan review and updates.

His physical health stabilized through consistent medication management, structured routines, nutrition support and proactive monitoring. This resulted in fewer falls, improved chronic disease management and far less reliance on emergency services. Robert’s mental health and wellness also improved significantly. Reduced isolation, increased engagement and a strong sense of safety, connection and control over his health made all the difference for Robert.. Calls for assistance became infrequent.

In May 2025, the research project ended and the Department of Social Development began funding Robert’s care.

In December 2025, DSD discontinued funding for comprehensive services to him. The service cost $41 per day.

Following this abrupt withdrawal of services, Robert’s condition deteriorated rapidly. In the first four weeks he suffered a fall requiring assistance. By eight weeks, he suffered another fall requiring 911 transfer to hospital where he remained for three months. During his stay in hospital, he experienced multiple falls and suffered further physical and functional decline, including the loss of independent walking due to prolonged immobility.

Upon discharge from the hospital at the end of May, there was a significant failure in discharge planning and continuity of care. Robert was transported home by ambulance and left on his couch, alone. No caregivers arranged. No functional assessment or safety plan evident. No supports to address his now significantly reduced mobility.

At the time of his discharge Robert was unable to walk independently. He was unable to access his bathroom or bedroom where essential supports were located, including a specialized bed and mattress required for his chronic debilitating pain and lower his high fall risk.

Robert has been confined to his couch day and night since discharge without the ability to safely meet his basic needs. His physical health continues to decline, and his mental wellness has further deteriorated, marked by isolation, loss of dignity and complete dependance without support. He has private home care that is intermittent and inconsistent.

So, let’s look at the timeline and the outcome.

-            2018 – December 2025: Thriving independently at home with comprehensive supportive care.

-            December 2025: Removal of services resulting in immediate loss of structure and care coordination

-            February 2026: A fall at home requiring a hospital stay

-            February to May 2026: Prolonged hospital stay with further decline and multiple falls

-            End of May 2026: Unsafe discharge home without supports leading to ongoing deterioration

Robert’s case highlights multiple systemic gaps:

-            The lack of vision to discontinue a service that was providing stability, without understanding the consequences.

-            The lack of continuity between community and acute care systems.

-            The absolute failure in discharge planning and functional assessment.

-            And the absence of post-discharge care.

Now, let’s also do the math. At $41 a day, supporting Robert would cost $14,965 per year. An acute care hospital bed costs $801 per day. In only three months, Robert’s care cost came in at $72,000.

The least expensive service, and most patient/client-centered way, would keep people in their homes for as long as possible AND it is the preferred choice for most individuals and families. It just so happens to also be best for the taxpayer.

Robert’s story amplifies how multiple systems do not recognize their own limitation and initiative to work together, to coordinate care through multiple departments and Regional Health Authorities. It further demonstrates significant resistance to utilizing community services that could do it for them.

Robert is now 62 and no longer living a life of quality.

This was preventable for $41 a day.