Integrated Transitional Services

Ontario Health-Toronto (OH-Toronto) in partnership with The Salvation Army Toronto Grace Health Centre (TGHC) has created a program to alleviate the alternate level of care (ALC) burden experienced by acute care hospitals.  At present, patients who no longer require the resources and services available in acute care settings often end up remaining in such settings as they wait for treatment in more appropriate environments.  ALC cases have been increasing, creating occupancy pressure on hospitals and health care providers.  This new Integrated Transitional Services (ITS) Program will provide support for ALC patients with bariatric requirements and patients with mental health and addiction requirements who are medically stable and have acquired a level of independence but continue to require a level of support before they can transition into the community.

The program provides a community setting on the top floor of The Salvation Army Toronto Harbour Light Ministries (THLM) at 160 Jarvis Street, Toronto.  The unit, which is staffed by a nurse, mental health case manager, professional support workers and unit clerk, has fifteen rooms, each equipped with a modern bathroom, a meal serving pantry, as well as a care station.  The goal is to transfer up to thirty patients to the ITS unit at the THLM from the OH-Toronto hospitals.

To support the TGHC in managing the program, OH-Toronto is providing program funding, resources from Reconnect Community Health Services (a community mental health agency), and a co-ordinator to navigate ALC patients from acute care facilities to the ITS unit, and ultimately back to the community.

The THLM will lend support with the program by providing a social worker with training in treating patients with mental health issues, as well as a chaplain to assist patients with their spiritual needs.  The social worker will facilitate recreational and social activities for the patients, and also provide co-ordination of mental health and addiction services within the community.

This ITS Program supports the TGHC’s goal of providing patients with a seamless health care pathway from acute care to the community.  When all stakeholders (OH-Toronto, TGHC, THLM, and Reconnect) are focused on the goal of providing ALC clients in a compassionate and exceptional health care environment, these clients with appropriate supports, are better able to successfully transition back to the community.

Integrated Transitional Services (ITS) – Referral Process