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.
Program Goals
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.
Program Structure and Partnerships
The Toronto Grace Health Centre’s (TGHC) A&R Program ensures that frail, high-risk seniors receive the right intensity of care at the right time and place. This is achieved through collaboration with key partners across three sectors:
- Acute Care: Unity Health – St. Michael’s Hospital (SMH)
- Complex Continuing Care/Rehabilitation: TGHC
- Community Care: WoodGreen Community Services
- Ontario Health – Toronto
These partnerships ensure that frail seniors are continuously linked with a primary care provider and receive the support they need before, during, and after discharge.
Care Transition Process
After medical assessment and treatment, frail high-risk seniors and others are guided by a discharge coordinator from acute care at SMH for placement at the TGHC. This ensures a smooth transition to the appropriate care setting.
Rehabilitation and Recovery
Patients admitted to the TGHC rehabilitation program receive a range of interventions, including:
- Sub-acute complex care
- Geriatric rehabilitative care
- Active recuperative interventions
While working toward their recovery goals, patients are supported by a team of healthcare professionals, including social workers and care coordinators.