Transitions from Acute Care to the Community

Question 1

Discharge Planning

Answer 1

Individualized plan of discharge to facilitate the transfer of a patient from hospital to a post-discharge setting

Question 2

Transitional Care

Answer 2

Interventions to improve transition from one care provider to another

Question 3

Acute Care of the Elderly (ACE)

Answer 3

Specialized geriatric inpatient unit

To provide coordinated, interprofessional geriatric inpatient assessment and treatment for older adults with acute medical issues

Question 4

Goals for an ACE Admission

Answer 4

a. assessment and enhancement of physical, cognitive and psychological functioning
b. provide evidence-based treatment of acute/chronic geriatric problems
c. facilitate the transition from hospital to community and prevent premature institutionalization

Question 5

Admission Criteria to the ACE unit

Answer 5

aged 65 or over:

a. presents with acute, complex medical illness and presence of one or more geriatric syndrome
b. has the potential to return to or close to pre-illness level of functioning

Question 6

ACE Unit Exclusion Criteria

Answer 6

a. requires intensive medical monitoring
b. resides or requires LTC support
c. presents with severe/end-stage dementia or terminal disease
d. presents with primarily an active psychiatric dx and/or behavioural issues not realted to delirium
e. designated ALC (alternate level of care)

Question 7

Discharge Destinations

Answer 7

1. Home
   (home, retirement home, LTC, supportive housing or shelter)
2. Rehab Program
   (PT/OT to determine once medically stable, goal is to progress back to baseline)
3. Other destinations
   (referral)

Question 8

Rehabilitation Programs

Answer 8

High-intensity Stream Program
- 2-3 weeks

Slow-intensity Stream Program
- 3-4 weeks

Transitional Care Unit
- waiting for LTC placement

Complex Continuing Care Unit
- require high nursing care

Question 9

Retirement Homes

Answer 9

• privately owned
• private accommodation to seniors who and live with little or no help, $1500-1600/mth
• may assess need to make sure that it can provide client with the right level of support
• meal plans or other services at extra cost

Question 10

Long Term Care Homes

Answer 10

• 24 hour nursing and personal care
• care is funded by government but client pays for accommodation charges such as room and board

Criteria:

• 18 or older, valid OHIP
• high nursing and personal care needs

Question 11

Criteria for Rehabilitation

Answer 11

Inclusion:

• either physical or cognitive goals to progress within 4 weeks max in program
• age will determine stream

Geriatric: over 65
Medical: under 65
Orthopedic: surgeries related to joint replacements/fractures
Amputee: amputee that have potential to transfer w/wo prosthetic

Exclusion:

• client from LTC
• does not want to participate daily in therapy sessions
• does not have carry-over due to cognitive impairment

Question 12

Social Determinants of Health

Answer 12

1. Income and social status
2. Employment and working conditions
3. Education and literacy
4. Physical environments
5. Social supports and coping skills
6. Healthy behaviours
7. Access to health services
8. Culture/race/gender

Question 13

Safe Discharge

Answer 13

A good discharge plan improves patient satisfaction and prevents readmissions

a. medically stable and capable enough to understand discharge plan
b. has a discharge destination
c. back to functional baseline or have access to mobility devices
d. have access to medications and understands how to take them
e. has been assessed for services (i.e. LIHN)

Question 14

Local Health Integrated Network (LHIN)

Answer 14

• non-profit, community-based, funded by MOHLTC
• coordinate care in collaboration with hospital team for patients returning to community from acute care
• can initiate and facilitate application for LTC

Services include:

1. PSW
2. RN
3. OT safety home assessment
4. Case Manager (care coordinator) to follow up