Exciting partnerships and innovations are happening across the sector, resulting in new models of care that are dramatically improving seniors’ care.

Transitional care

Enabling people with complex care needs to transition out of hospital

An Extendicare and Ottawa Hospital partnership

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In 2021, The Ottawa Hospital and Extendicare began to collaborate on plans for an innovative transitional care unit that is now serving as a model for tackling one of the health system’s most persistent challenges. Their partnership, built on a relationship forged during the COVID-19 pandemic, is leading to better hospital access for people in the community and better rehabilitative care for seniors with complex care needs, and others who need support.

Like many Canadian hospitals, The Ottawa Hospital has been facing capacity challenges. Across Canada, an increasing number of beds are occupied by people who no longer need the level of care provided by hospitals, but who are unable to live independently and are waiting for additional supports or another community-based care setting such as long-term care.

With wait lists for many health services under pressure, it is not uncommon for these patients, designated “alternate level of care” or “ALC,” to wait in hospital for weeks or months before moving to the care destination most suited to their needs. The majority are seniors. Prolonged hospitalizations, which offer limited opportunities for social stimulation and physical mobility, can negatively impact a patient’s well-being, lead to a significant loss of muscle tone, and accelerate symptoms of dementia.

Transitional care approaches provide a missing link in the health care system and are becoming more common across Canada, through a variety of different models of care and governance. The Ottawa Hospital/Extendicare unit, located in Extendicare’s West End Villa long-term care home, features an integrated team of staff from both organizations. Extendicare staff provide support with meals, activities, well-being supports and housekeeping, while hospital physicians and nurses provide care and clinical oversight, beyond what would normally exist in a traditional long-term care home.

The unit began with the ability to care for 55 patients departing hospital, and after a year of successful operations Transforming care to serve people better The Ottawa Hospital and Extendicare partner on an innovative transitional care unit for alternate level of care patients on a single floor, has since expanded to a total of 100 beds on two floors. It has freed up hospital spaces for those who need them, offers a more suitable and comfortable environment for seniors with ongoing and complex care needs, and provides care to former ALC patients in the community, at a lower cost to the health care system.Listen to the podcast discussion


Improving care and reducing hospitalizations for people with dementia and responsive behaviours

A Baycrest program available across Ontario

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A virtual program to assess and treat people with challenging behaviours caused by dementia and related cognitive disorders is helping long-term care homes, as well as hospitals and family caregivers, to provide better care for people living with dementia.

Launched in April 2020, the Virtual Behavioural Medicine (VBM) Program is a collaboration between the Sam and Ida Ross Memory Clinic at Baycrest and the Toronto Central Behavioural Support for Seniors Program housed at Baycrest, which sees patients through virtual visits over the secure Ontario Telemedicine Network rather than in person.

Individuals with challenging responsive behaviours, such as physical and verbal aggression, agitation, hallucinations and paranoia, receive pharmacological and nonpharmacological interventions to mitigate their behaviours.

Among the benefits of the VBM Program is that its team of specialists – including neurologists, a nurse, a social worker, a pharmacist and the BSO team – can provide a rapid response where and when they are needed. They work with care teams in long-term care homes, as well as with acute care hospitals and family members in the community, to help them develop and implement care plans, access behavioural and social supports, and provide follow-up.

Analysis shows that before a consult with the VBM program, 96% of people were in clear need of admission to a specialized neurobehavioural unit. After implementing the program, only 38% needed inpatient care.

Two stories from long-term care homes show the significant impact of the program.

The Apotex Centre, Jewish Home for the Aged, had a new admission with behavioural symptoms of extreme aggression, both verbal and physical. The individual needed security and extra staff 24 hours a day. A referral was made to Dr. Morris Freedman, Head, Division of Neurology, Baycrest, who explained that he could assess the resident without seeing them in person. There was no need to transfer them to an in-patient unit.

Behaviours improved with the VBM’s two-pronged intervention approach. “Dr. Freedman came on board along with the Long-Term Care Behavioural Support Outreach Team,” said Shitu Wang, the Behavioural Supports Resources Team Lead at the home. “It took two months of sustained work with our team using medications and nonpharmacological  interventions identified by the Behaviour Support Team. The results were especially positive with conversations and activities all done virtually.”

When the Downsview Long-Term Care Centre in Toronto referred a resident with physical aggression to the VBM Program, there were similar results. The resident was quickly assessed, and the program worked collaboratively with their interdisciplinary team to develop and implement effective strategies to stabilize their condition. Following this, the resident no longer required one-to-one monitoring. “It’s like having a virtual Behavioural Neurology in-patient unit in each location,” says Dr. Freedman. “And just like on an in-patient unit, we have weekly rounds to review patients as a team.”

The VBM program has also implemented bi-weekly case review rounds involving the whole team to look at each case and ensure that any gaps are filled, all available resources are optimized, and a transitional plan and supports are in place for a person’s discharge from the program.

A physician referral is necessary to access the VBM program. Referrals are processed through the TC-LHIN Behaviour Support Hotline at Baycrest. Health care practitioners requiring support can contact the BSO Hotline seven days a week, from 8:30 a.m. to 4:30 p.m., including weekends and holidays, to be connected to support as well as to the VBM program as needed.

Visit the Baycrest website to learn more


Making it possible for older adults who experience frequent or severe behavioural expressions to move out of hospital

A pilot by Schlegel Villages

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In the spring of 2021, Ontario hospitals were experiencing a surge in admissions resulting from the fourth wave of COVID-19. The Ontario government appealed to long-term care homes to increase admissions of patients from hospital, particularly those who are classified as Alternate Level of Care (ALC).

Within the ALC patient population, there is a subset of patients who experience frequent or “severe” behavioural expressions as a result of dementia, brain injury and/or mental health diagnoses. It is historically difficult to find spaces for these complex patients in most conventional long-term care homes because of concerns about risk.

Recognizing that this subset of ALC patients does not thrive in a hospital setting, Schlegel Villages proposed a pilot project on a dedicated floor in the Erin Mills Lodge Long-Term Care Home in Mississauga. A 20-bed Enhanced Supportive Neighbourhood (ESN) pilot project was approved for referrals from local hospitals. The ESN was designed as a temporary home for an anticipated period of 30 to 180 days for residents, with a goal of ultimately helping them to transition safely into an appropriate admission within the conventional long-term care home system.

Model of care

The ESN is staffed by a team that believes relationships, consistency and a gentle, respectful tone can be more effective than restraints, confrontation and antipsychotic medications when it comes to people living with dementia. It’s a supportive environment that allows freedom of movement to combine with a supportive team approach, relationship-centred training, and increased staffing levels in 12-hour shifts alongside a collaborative clinical team.

Success also hinged upon the training and support the entire team has received. LIVING in MY Today is the dementia program and philosophy used at Schlegel Villages to support residents living with dementia. Team members from every discipline participated in the LIVING in MY Today training together to ensure all team members share the same understanding and use the same approaches to support residents. Each team member interacts with residents in different ways, and through this relational approach to care, residents are treated with empathy, kindness and respect as people first, and not as tasks to complete.

The fact that the same dedicated team members work on 12-hour shifts means the relationship between the team member and resident grow deeper and the days move by with fewer transitions and less pressure to accomplish “tasks” before a shift change.

Each team member is also allocated one hour per shift for no other purpose than resident interaction: they can chat over a cup of tea, read together, sing and dance or simply sit quietly in each other’s presence. The team members report they get as much out of this time as the residents.

The ESN’s model of care includes the following unique features:

  • Relational care approach;
  • Twelve-hour shifts;
  • Dedicated support (consistent assignment);
  • One hour of dedicated resident engagement time for each personal support worker (PSW) per shift;
  • Intentional environmental design; and
  • No high intensity needs funding (for one-on-one support).

Physical space

Schlegel Villages repurposed an outdated, empty retirement wing within their campus of care to accommodate the ESN. The goal was to transform the space into a safe and supportive physical environment to promote resident independence, mobility, engagement and comfort. The decor is intentionally familiar and homey, in contrast to the clinical tones of a hospital environment.

Each resident has their own private room with bathroom and shower, as well as their own television with WiFi capability in order to access programs and music to suit their preferences. That space is considered their sanctuary, while the common areas are decorated with intentional artwork that uses single focus, real-life images to break the monotony of the view and create visual cues and landmarks to support residents in finding their way.

A multi-purpose room is used for dining as well as engagement throughout the day. There is a servery space attached where food and drinks are available to residents 24 hours a day, supporting team members to respond to residents’ hunger and thirst in the moment, not according to an imposed, institutional schedule.

Partnerships matter

The care provided to the residents who call the ESN home is made possible through collaboration with key partners within and outside of the Ontario health care system to ensure optimal quality of life for residents while they are living in the ESN and also a smooth transition into and out of the ESN. These partners include, but are not limited to, the partner hospitals, the Ministries of Health and Long-Term Care, Ontario Health Team (Central), Behaviour Supports Ontario, Alzheimer’s Society, Home and Community Care Support Services, Mind Forward Brain Injury Services, and the Nurse Practitioner Teams Averting Transfers. The Schlegel-UW Research Institute for Aging is partnering on the project to support the evaluation of the pilot.

Preliminary results show significant promise

Preliminary evaluation results show that the ESN helps people labelled “high risk” who risk languishing in a hospital with ALC designation for the rest of their lives. The majority of residents were able to meet their clinical goals within the targeted amount of time and many have transitioned successfully into conventional long-term care homes.

In the spring of 2022, at the time of writing, no residents had been transferred back to hospital or sent to the emergency department for anything that was potentially avoidable or related to their dementia or mental illness. The ESN was always designed to be transitional and those who have been stabilized and have transitioned to new long-term are homes continue to do well.

The ESN improves quality of life for these individuals, while also improving health care system flow and efficiency. Having more intensive and appropriate supports eases family anxiety and helps to restore their trust in the health care system, and provides team members meaningful and enjoyable work, which translates to lower absenteeism and turnover.

The ESN pilot received higher funding than traditional long-term care, which allowed them to provide enhanced care and support. This provided a better quality of life for individuals at substantially lower cost than staying in hospital with estimated cost savings to the health care system of $1.13 million per year.

Schlegel Villages is awaiting a renewal of funding for ESN for another year. While some further analysis still needs to be done, the pilot study has shown significant promise for an expanded Enhanced Supportive Neighbourhood approach in homes across the province.