Assess and Restore Program

The Assess and Restore (A&R) Program is designed to promote the rehabilitation of frail seniors and other persons who have experienced a recent loss of functional ability, either following a medical event or a decline in health; are at risk for imminent hospitalization or admission into a long-term care home as a result of that functional loss; and have the potential to reverse that functional loss so that they are no longer at high risk.  Ultimately, the goal of the A&R Program is to extend the functional independence of community-dwelling frail seniors and other persons for as long as possible, as well as to reduce caregiver burden by improving psychosocial and health outcomes.

The TGHC’s A&R Program provides frail high-risk seniors with the right intensity of care at the right time and place.  Utilizing health system resources and partnerships in three sectors — acute care (Unity Health-St. Michael’s Hospital (SMH)); complex continuing care/rehabilitation (TGHC); community care (WoodGreen Community Services); and Ontario Health-Toronto — frail seniors are continuously linked with a primary care provider and received the support they needed before, during, and after discharge.

After medical assessment and treatment, frail high-risk seniors and others transition with the guidance of a discharge coordinator from acute care at SMH for placement at the TGHC.  Patients admitted to the TGHC rehabilitation program receive sub-acute complex interventions, geriatric rehabilitative interventions, as well as active recuperative interventions.  While these patients work on their recovery goals, and prior to their discharge, the social worker at the TGHC works closely with a care coordinator to better transition the patient back to the community.  Frail seniors and other persons re-entering the community are provided with an appropriate plan of care and are closely monitored.  Any potential signs of decline in a patient will trigger re-admission to the TGHC for additional rehabilitation to maximize their health, prevent deterioration in functioning, as well as emergency room visits.