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Programs & Services
Referring Partners
Transitional and Continuing Care Program
Transitional and Continuing Care Program serves medically complex and/or orthopedic patients whose conditions require a hospital stay, regular onsite physical care and assessment as well as active care management from an interdisciplinary team. As members of the Total Joint Network we also offer slower paced rehabilitation to frail elders who have experienced a hip fracture with the goal of returning to the community.
Admission Criteria
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Adults, 18 years and older
Patients have goals for at minimum two therapeutic interventions (e.g. nursing for wound care, physiotherapy, speech language pathology etc.)
Patients have an anticipated ability to learn and participate in care.
Patients who are not presently suitable for acute rehabilitation or who have completed an acute rehab program but still requires longer duration restorative/reconditioning care. Referrals accepted from acute care, rehabilitation, long-term care, CCACs, community services and/or primary care practitioner/teams.
Referrals accepted from acute care, rehabilitation, long-term care, CCACs, community services and/or primary care practitioner/teams.
Medical conditions accepted include:
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Parkinsons,
Strokes,
mental health impairment,
musculoskeletal surgery/injury,
diabetes,
deconditioning as a result of prolonged hospitalization.
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Patients care needs may include non-ventilated tracheostomy care, enteral feeding, ostomy care and wound management.
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Total Joint Network Hip Fracture Program
Program Description:
As part of the Total Joint Network Hip Fracture Integrated Model of Care, patients admitted to this service have experienced a hip fracture with or without surgery, and require interdisciplinary rehabilitation services for an extended period of time.
The focus of care is a low to high intensity therapy program to enable patients to improve functional ability and maximize level of independence. Anticipated length of stay is approximately 1-3 months.
Specialized areas of service include:
1. Slow Paced Rehabilitation: low intensity, longer duration restorative care to reach an optimal level of function for reintegration into the community
2. Provision: of ongoing medical management, skilled nursing, and a range of interprofessional therapeutic services
3. Interdisciplinary Team Approach: medicine, nursing, physiotherapy, occupational therapy, speech language pathology, pharmacy, nutrition services, therapeutic recreation, social work, spiritual care and chiropody.
Admission Criteria
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Adults, 18 years and older
Patients have goals for at minimum two therapeutic interventions.
Patients have an anticipated ability to learn and participate in care.
Patients who are not presently suitable for acute rehabilitation. Patients may require a period of minimal or no weight-bearing prior to their participation in an active rehabilitation program.
Patients who have experienced a significant medical complication during their surgical, post-op or post fracture event (e.g. myocardial infarction, neurovascular event, wounds, infection, etc.).
Patients who are not able to meet clinical milestones for discharge to the community within the pathway time frame
Patients with previous co-morbidities that impact their tolerance to rehabilitation participation (e.g. moderate dementia, chronic mental health co-morbidities, etc.)
Patients who have completed an active rehabilitation program but still require longer duration restorative/reconditioning care.
Patients with complex medical and/or nursing needs unable to return to Long Term Care on day 5.
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Contact Information:
Transitional Care Program, 5th Floor
Phone: 416-925-2251 ext 218
Admitting fax: 416-925-3211
Jane Sanders
Patient Care Manager, ext. 217
Michelle McDonell
Admitting Coordinator, ext. 230
Jodi Zaltz-Dubin
Social Worker, ext. 242
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