Helping frail senior patients transition from hospital to home

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Our Stories

Helping frail senior patients transition from hospital to home

Toronto, September 30, 2016

By Kaitlyn Patterson

Kim Grootveld and Hyunja Sung help Cyril Moore into transportation
Kim Grootveld, case manager for the General Internal Medicine unit, and Hyunja Sung, a personal support worker for WoodGreen Community Services, help Cyril Moore into transportation for participation in WoodGreen’s adult day program. (Photo by Katie Cooper)

When frail, elderly patients who have suffered a health issue such as an infection or a fall no longer need to remain in an acute care hospital, that doesn’t always mean they are ready or able to go home. Yet it can sometimes be challenging to find a smooth way of transitioning them back to the community and preventing hospital readmissions.

St. Michael’s has partnered with Toronto Grace Health Centre, Toronto Central Community Care Access Centre and WoodGreen Community Services for a rehabilitation project aimed to make those transitions more seamless. The project will help frail senior patients receive the supports they need before, during and after discharge, while also freeing up beds in St. Michael’s General Internal Medicine and Acute Care of the Elderly unit.

Ontario’s Toronto Central Local Health Integration Network is supporting several projects aimed at rehabilitation for seniors. The programs are known as Assess and Restore.

“There was a gap in care for patients in acute care beds that didn’t need to be there, but who were not yet ready for independent living without rehabilitation,” said Kim Grootveld, case manager for St. Michael’s General Internal Medicine unit. “We’ll evaluate whether Assess and Restore improves the quality of life for our seniors by providing them with a rehabilitation period, social interaction and a plan to help them transition out of hospital and into the community.”

Physicians and the geriatric inpatient consultation team assess patients who are between ages 55 and 105 and have physical, functional or cognitive decline, such as decreased mobility or dementia. The team assesses these patients on a clinical frailty scale. A one on the scale means the patient is independent; a seven, eight or nine means the patient requires substantial support for daily living.

Assess and Restore is for patients who are considered a four to six on the scale. These patients are referred to Toronto Grace, where 10 rehabilitation beds are reserved per month for the program. Patients receive rehabilitation for up to six weeks, while working toward their recovery goals.

“This partnership means that CCAC and community partners are involved early, which is instrumental to ensuring our patients get access to the appropriate services we know they deserve.”
- Natalia Zapata, physiotherapist, General Internal Medicine

Before these patients return home, a CCAC care co-ordinator supports their transition by setting up services such as Meals on Wheels to help patients maintain their independence.

“This partnership means that CCAC and community partners are involved early, which is instrumental to ensuring our patients get access to the appropriate services we know they deserve,” said Natalia Zapata, a GIM physiotherapist and co-ordinator for the partnership involving St. Michael’s.

CCAC can also enrol patients in senior-friendly day programs. WoodGreen’s day program runs weekdays from 10 a.m. to 3 p.m., which is helpful for patients whose families are unable to provide care during the day. Programming focuses on physical activity and interaction with other seniors.

“Co-ordinating acute care is difficult because we have to balance the flow of patients with quality of care,” said Grootveld. “We’re learning about the most effective way to work with other organizations for this patient population, but hope to see that Assess and Restore can help us strike this balance and empower patients to return home.”

The Assess and Restore program has served 20 St. Michael’s patients since it began in November.

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael's Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.

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