March 2017

Following a serious illness or injury that requires hospitalization, we know that the vast majority of people want to return to their home and live independently. Unfortunately, for some people, most notably seniors with higher care needs, returning home immediately following a hospital stay is not always an option.

At the HNHB LHIN we are working to ensure that all residents get the care they need, where and when they need it. This month I am excited to talk about an incredibly successful initiative that is doing just that: the HNHB transitional care service model – known by many people as the Transitional Care Program.

In 2014, after years of steady improvement, a rising trend in the Alternate Level of Care (ALC) rate was detected at hospitals across our region. Lengthy wait times for placement in Long-Term Care and a lack of other care options were resulting in unnecessary, extended stays in hospital for far too many people. The HNHB Transitional Care Program was launched to help address this gap in care options. The Program, which began as a collaborative effort between the LHIN, the HNHB Community Care Access Centre (CCAC), Hamilton Health Sciences and St. Joseph’s Healthcare Hamilton, and now includes retirement homes and assisted living providers, was designed to create alternative, community-based options for patients who, while ready for discharge from acute care, are unable or not yet able to return home. Sara’s story – later in this blog – is a great example of transitional care at work.

Patients like Sara, who are awaiting an ALC, are medically stable and well enough to be discharged to a community setting, but for a variety of reasons often remain in hospital. Some are awaiting placement to Long-Term Care and will never be able to return home because their support needs are too great. Others simply require additional time to recover before they can safely return home or need to make alternate living arrangements as their needs have changed.

We know that unnecessarily long stays in hospital are not in the best interests of patients. People who experience extended hospitalization are at an increased risk of deconditioning and exposure to hospital acquired infections and that the longer someone remains in hospital, the more likely they are to require placement in Long-Term Care.

When a significant percentage of beds are being occupied by patients who could be better cared for in a community setting, it also puts significant pressure on our hospital system and can affect access to acute care services. In addition to redirecting limited resources from patients in greater need, high ALC rates have a cascading effect on patient flow across the hospital. This can affect the hospital’s ability to move patients between units because space is unavailable, can cause long Emergency Department wait times for patients requiring admission and can delay scheduled surgeries.

This is where the HNHB LHIN Transitional Care Program makes a difference. Leveraging existing relationships and capacity in private sector retirement homes and assisted living facilities, the Program is able to offer alternative, community-based care environments for patients who would otherwise be waiting in hospital. These environments provide a temporary, safe and restorative setting where individuals can continue recovering their strength and independence while giving them the time they may need to make suitable living arrangements as needed for the future.

The goal of the Transitional Care Program was to develop alternative discharge destinations and reduce the number of patients who wait in hospital for an ALC, while also optimizing health outcomes by enabling these individuals to receive care in a home-like setting and supports designed to meet their specific needs.

In addition to providing better overall care for patients, Transitional Care is also significantly more cost effective than providing care in hospital. With an average daily cost of approximate $191 per bed, Transitional Care costs less than a quarter of the $840 daily average for an acute care hospital bed and less than half of the $401 daily average for a convalescent care bed.

The HNHB LHIN’s annual investment in Transitional Care has grown to approximately $8 million annually and, as of December 2016, the Program had expanded to 209 beds across 16 sites, including:
  • 7 sites in Hamilton with a total of 133 beds
  • 4 sites in Burlington with a total of 30 beds
  • 3 sites in Niagara with a total of 29 beds
  • 2 sites in Brant with a total of 17 beds
More than 1,700 patients have been admitted to the program since 2014, resulting in more than 82,000 avoided hospital ALC days.

While better utilization of limited hospital resources and opening beds for patients in greater need of acute care are notable accomplishments, the true impact of Transitional Care is how it translates to improved experiences for patients like Sara.

After having both legs amputated due to Vascular Disease and spending a number of months in hospital, Sara was transferred to a Transitional Care bed at First Place Assisted Living in Hamilton. When she arrived at First Place, Sara was very optimistic about going home. Her family and medical team, however were concerned that because she required assistance with daily tasks she would be unable to cope in her own apartment.

During her stay at First Place she regained her strength and with staff support was able to show her independence by transferring herself to and from her own wheelchair. Eventually, she regained her mobility by demonstrating she could transport herself to the dining room and other events throughout First Place.

After two weeks it was determined that Sara could manage on her own and she was able to move back into her apartment and live independently with the assistance of community supports.

Sara’s story is just one example of the difference that the HNHB Transitional Care Program has made for patients and families in our LHIN. Though the program has been tremendously successful, we are working to further strengthen the program by:
  • Expanding access to transitional beds across the LHIN to further reduce hospital ALC rates;
  • Enhancing available supports, including therapeutic programs and skilled nursing to increase discharges to destinations other than LTC; and,
  • Continuing to develop programs geared to better meet the needs specific populations including those exhibiting responsive behaviours and those with dementias.
The Transitional Care Program is a positive example of providers coming together to put patients first and meet their needs, while also addressing system challenges in an innovative and collaborative way.

We know there are other stories like this in our LHIN and we want to tell them.


If you or your organization would like to be featured in a future blog or share a patient story in one of our Voices in the Community videos you can reach us through our office, or if you’re on social media via our Twitter handle -@HNHB_LHINgage. Your feedback and questions are always welcome.