Long-term care (LTC) homes provide housing with clinical care and health and social supports for adults who can no longer live independently. Delivering this care has been a challenge over the last year, as COVID-19 has placed unprecedented stress on LTC homes across Ontario, including those in the Greater Toronto Area (GTA).
In October 2020, the Ontario Ministry of Long-Term Care and the Ontario Ministry of Health asked The Salvation Army Toronto Grace Health Centre (TGHC) to work with the University Health Network (UHN) to establish a ninety-bed Specialized Care Centre (SCC) to assist LTC homes in delivering patient care in the GTA. On December 28, 2020, the SCC was opened at the Toronto Congress Centre at 650 Dixon Road in Etobicoke.
The SCC provides emergency surge capacity for the temporary relocation of LTC residents from facilities dealing with COVID-19 outbreaks or other challenges, including, amongst other things, staff shortages, lack of supplies, infrastructure issues, safety issues, or outbreaks of other diseases, such as influenza.
The SCC operates as an extension of the TGHC, delivering a model of patient- and family-centred care that follows our principles of quality care for frail seniors. The SCC is staffed by the TGHC’s interprofessional health care team: a medical director, who is a geriatrician; a director of operations; a hospitalist; an infection prevention and control practitioner; patient care managers; registered nurses (RNs); registered practical nurses (RPNs); personal support workers (PSWs); an occupational therapist (OT); a physiotherapist (PT); a mental health occupational therapist; a social worker; a chaplain; a pharmacist; and offers diagnostic services as well as laboratory technical services.
This is the story of one SCC patient.
Kathleen’s Story
Kathleen is sixty-seven years old and was diagnosed with multiple sclerosis (MS) over thirty years ago. In early December of 2020, while transferring from her electric wheelchair to her walker, she tripped over bandages she was wearing and fell. The bandages were being used to dress wounds on her legs caused by bullous pemphigoid, a disease that involves the immune system.
Kathleen experienced considerable pain in her right hip following her fall, but she did not immediately seek medical attention. Eventually, though, the pain became unbearable and she became unable to transfer to her wheelchair unaided. Kathleen visited the ER at Toronto Western Hospital (TWH), where an X-ray of her pelvis showed a right femur hip fracture. Since Kathleen’s fracture displayed a stable pattern, her orthopedic surgeon decided that, given Kathleen’s immunocompromised status, it would be best to manage her injury nonoperatively. She was transferred on December 11, 2020, to the UHN’s Toronto Rehab – Bickle Centre for low-tolerance, long-duration rehabilitation. There, her hip fracture was conservatively managed with pain medication, physical therapy and no weight bearing on the affected hip for a period of six weeks.
“At Bickle,” says Kathleen, “I received good rehabilitation. My physiotherapist and occupational therapist were wonderful. I felt I was making progress. However, at a certain point I was told that I was going to be moved to another facility.” In an effort to support the maximizing of acute care bed capacity generated by the COVID-19 pandemic Kathleen was discharged from the Bickle Centre and admitted to the TGHC’s Specialized Care Centre on April 22, 2021. The decision to transfer patients like Kathleen, who no longer required the extra resources and services provided by their care settings into facilities like the TGHC/SCC, was arranged to enable bed capacity and patient flow across the health care system.
The plan was to later transfer her to an LTC home when a space became available. However, Kathleen felt that she needed to return home to her apartment to look after her son Darryl, who also suffers from MS — in his case, though, the disease is at a more advanced stage.
Her son’s situation began to deteriorate while Kathleen was at Bickle and got worse during her stay at the SCC. Darryl suffered an “exacerbation” — the term is used for the development of new MS symptoms or the worsening of old symptoms. Because of his worsening condition, Darryl was unable to transfer out of his wheelchair. The PSWs were able to attend to his activities of daily living, but his buttocks were developing pressure injuries. He needed to go to the hospital. Kathleen tried desperately to convince her son to seek medical help, but he was concerned that he would be infected with COVID-19 because of his compromised immune system. However, Darryl finally acquiesced and is currently in hospital receiving care for his pressure injuries.
Kathleen was provided with all the SCC services including ongoing rehabilitation. “When I first came to the SCC,” says Kathleen, “I wasn’t doing well psychologically – I was a mess- and I thought, What is this place? However, as I got to know the health care staff, who were so helpful, caring, and kind, I got better. They’re willing to really listen to you and Dan was so supportive.”
Dan, a Patient Care Manager at SCC, introduced himself to Kathleen. “I always try to connect with patients, so I can get to know them after they’re admitted. I ask them how their stay at the SCC is progressing and for them to tell me their medical history,” says Dan. In his meeting with Kathleen, she pleaded to be allowed to return home. She said that she needed to be with her son and not in an LTC home. Dan assured her that he would look into her case.
Dan’s experience working in the community and with community care partners provided him with the knowledge of who to consult to help Kathleen. He connected with the Home and Community Care Support Services (HCCSS) Coordinator to review Kathleen’s eligibility criteria for returning to the community. The HCCSS Coordinator explained that while Kathleen was in- hospital they had tried to arrange services in her apartment a number of times, but because of the heavy care needs and the demand for PSWs, they were unable to fulfill the requirements for sending her home. As a result, HCCSS had determined that Kathleen had to be placed in a LTC home. In the interim, she was required to stay at the SCC until she could be admitted to a LTC home.
Not accepting the conclusion that there was no option for Kathleen but to go to a LTC facility, Dan asked the HCCSS Coordinator if they could further collaborate on Kathleen’s case and possibly find a way where she could return home. He wanted to reach out to the service providers associated with the TGHC/SCC to see if they could help with Kathleen’s heavy care requirements. For Dan, the key question was, “What would it take to get Kathleen home?”
“With Kathleen’s permission,” said Dan, “a plan was devised. First, an application was made to West Neighbourhood House to receive high-intensity-needs funding. Once this was approved and support from TGHC/SCC and a few community care providers, mainly the Ontario Disability Support Program (ODSP), the HCCSS, and Bloomcare had been organized, the plan was implemented.”
Because Kathleen’s case was complicated and a complex mix of services was required to allow her to return home, Dan approached Bloomcare, a digital health and services company. Bloomcare specializes in providing Alternative Level of Care (ALC) for patients who are discharged from a hospital so that they can safely return to their homes.
Bloomcare conducted an assessment of Kathleen’s file and concluded that they could take her case. The staff at Bloomcare determined what was needed and prioritized the next steps. An OT assessed Kathleen’s home and concluded that it required a thorough cleaning. It was also decided that Kathleen needed enhanced mobility aids. Before her fall, Kathleen was fairly independent and was able to get around her home using her electric wheelchair and transfer to her bed using a saska pole (a floor-to-ceiling pole that provides support to those needing it when standing up or transferring from one surface to another). After her fall, the pole was not adequate to meet Kathleen’s needs. It was decided that for her to successfully live independently when she returned home, she would require a hoyer lift for her to be able to transition to her bed or wheelchair. Bloomcare’s team further assessed that PSWs would require training in the operation of the lift.
Once the integrated transitional care services, from in-house cleaning, OT and nursing assessments, equipment ordering, and the training of the PSW’s was in place, Kathleen was discharged home. On August 10, 2021, Bloomcare began providing services to Kathleen in her apartment.
Although Kathleen was discharged from the SCC, Dan says she will still be a patient of the TGHC. Living in the community, she will be part of the Remote Care Monitoring program established by the TGHC (see Programs and Services Toronto Grace website). She will have an in-home medication dispenser (it automatically controls and dispenses her medication), and Kathleen will wear a fall pendent. The pendent is directly connected to the 24-hour remote-care monitoring call centre. If she has any medical issues, pain, a question, needs a wellness visit, or, for example, is locked out of her apartment, she can use her pendent to speak directly to the call centre.
Kathleen’s case illustrates how an Integrated Transitional Care Model can help a patient return home, as well as helping to avoid readmission to acute care. “No significant discharge planning,” says Dan, “is required for patients transferring from the SCC to their LTC home. However, in Kathleen’s case, the SCC quickly found ourselves in the role of providing her with an integrated discharge plan that would, with the aid of a lot of people and community care providers, contribute to her safe return home where she could continue to live independently.”
With all the integrated services provided by community partners, Kathleen and her son, Daryl, who was hospitalized to treat pressure injuries that he had developed at home, will both benefit and be able to safely return home. In this case, two family members, a mother and son, will be reunited and be able to continue to live independently.
A few weeks after Kathleen returned home, a team member from Bloomcare called her to follow up with her. “Do you know where I am?” asked Kathleen. I’m sitting in a coffee shop. I’m so happy I’m on the verge of tears because I haven’t been able to do this for a very long time.”
“It’s the ability to listen to your patients and to show compassion,” says Dan, “that makes a defining difference in Kathleen’s case. All the community partners from West Neighbourhood House, ODSP, HCCSS, and Bloomcare united with one goal, and through the provision of all the integrated services with the support of the TGHC/SCC, they were able to return Kathleen safely back to her home where she could continue to live independently and help her avoid acute care readmission in the future.”
By Gerry Condotta