A number of innovative partnerships and programs in The Scarborough Hospital’s (TSH) Specialized Geriatrics program are improving the care and coordination of support services for frail seniors in Scarborough.
“We are very excited to broaden our partnerships with Carefirst Seniors and Community Services Association, St. Paul’s L’Amoreaux Centre and TransCare Community Support Services to further integrate our services to support the care of seniors in the community,” said Nancy Veloso, Patient Care Director, Medicine, Geriatrics and Oncology at TSH.
“We appreciate the funding investment and support from the Central East Local Health Integration Network (Central East LHIN) to allow us to design and implement innovative service models that can best meet the needs of our community. This support has enabled us to greatly enhance the transition process from hospital to home for seniors and help them avoid future hospital readmissions.”
In partnership with Carefirst, TSH launched the “Assess and Restore” program to support elderly patients in returning home again by integrating services available at Carefirst into the patient’s discharge plan before they even leave the hospital.
Patients being discharged from hospital who are identified to be at especially high-risk for hospital readmission can also be referred to the six-week “Virtual Ward” program. In the Virtual Ward, social workers from both TSH and Carefirst act as ‘navigators’ who reach out to discharged patients to ensure they fill prescriptions, attend follow-up appointments with their family doctor or specialist, and receive ongoing health education.
“Our partnership with The Scarborough Hospital’s Specialized Geriatrics program allows us to become an integral part of the patient’s health care team and be able to truly understand their needs so services are ready the day they return home from the hospital,” said Alice Mui, Program Director of the Chronic Disease Management and Prevention Program at Carefirst.
Several months ago, the Central East LHIN announced the expansion of the GAIN (Geriatric Assessment and Intervention Network) Clinic at TSH to provide outreach into the community in partnership with Carefirst and St. Paul’s L’Amoreaux Centre. This is an initiative that demonstrates collaboration between hospitals and community service agencies to provide the ongoing support and care to seniors in the community that most need specialized attention.
TSH’s “Wrap Around Services”, a trial project initiated in collaboration with TransCare and the hospital’s social work team, assists patients who need additional services to help them return home, such as respite resources like overnight caregiver relief.
“There has been great value in having an on-site Community Support Services Coordinator from TransCare be part of the Wrap Around Services project at The Scarborough Hospital,” said Gurprit Matharu, Director of Integrated Care at TransCare.
“We are able to assess each client on a case-by-case basis and support them from the time they are in hospital through to their transition home and back into the community, addressing their needs over a short or long-term basis, as needed.”
TSH has also expanded on pre-existing initiatives in its Specialized Geriatrics program. Additional therapy services have been invested to the Geriatric Activation Program (GAP). GAP is focused on optimizing the functional and cognitive status for patients on the hospitalist general medicine units to enable them to return home again upon discharge.
For more information on The Scarborough Hospital’s programs and services for seniors, visit http://www.tsh.to/areas-of-care/seniors/.