Supporting patients beyond hospital walls

For many patients who are ready to leave hospital after a long stay either to a congregate care setting such as a long-term care home or into their own home, finding the right support to ensure a seamless transition back into the community can be overwhelming for both the patient and their loved ones.

Markham Stouffville Hospital (MSH) has a program to help patients that are medically stable and can be safely transitioned from the hospital into the community and/or an appropriate congregate setting.

[email protected]+ offers home visits, phone calls, virtual visits, caregiver support, transportation, community support services (such as Meals on Wheels), and specialized behavioural supports and outreach.

“This program is made possible with the support of our partners: South East Geriatric Outreach Team, LOFT (IPOP and Behavioural Support Services), CHATS (Community and Home Assistance to Seniors), and SE Health,” says Mandy Lau, Interim Planning and Integration Manager at Oak Valley Health which includes MSH. “We understand the challenges faced once patients are discharged from hospital and understand that there may be uncertainty around the level of care received once at home.”

The program allows for the [email protected]+ team to connect with the patient’s specialists, health care providers and family doctor to ensure the patient’s goals are being met, they are stable, and to help identify other services that may be beneficial such as nursing, physiotherapy, occupational therapy, speech language therapy, dietitian, and personal support workers.

To ensure the program fits the needs of the patient, there is an initial virtual meeting that takes place with the patient and their caregivers.

If the program meets the needs of the patient, an initial home care plan is created for the first 72 hours, followed by a home visit within the first 24 hours of accepting the program.

After six weeks in the program, patients are evaluated every four weeks to ensure they are meeting their goals. Once the patient is stable and milestones are met, the team will then connect with home and community support services to review and reinstate support services, and refer the patient to out-patient programs and to community support services as needed.

If you think you or a loved one can benefit from [email protected]+, call Transitional Care Lead Emma Rezaei at 647-394-4531.

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