Toronto Rehab’s Transitional Care Unit
The team on Toronto Rehab’s Transitional Care Unit meets each morning for STAR (Stop, Think, Act, Review) rounds, to help ensure their patients’ medical conditions remain stable for discharge. (Photo: UHN)

Monica Chapman first arrived at Toronto Rehab's Bickle Centre five years ago after a debilitating ulcer, compounded by other health complications, disrupted her life.

As her health slowly started to stabilize, it became evident that she wouldn't be able to return to the community she once thrived in. She needed to find an alternative home with the right supports in place, and until the right fit came along, Bickle became that home.

"I was eager to be discharged, but didn't think I could be," says Monica, 53.

Enter Toronto Rehab's Transitional Care Unit (TCU), which opened in October 2017. Its goal was like any other at UHN: to help ensure that the right patient was in the right place, and being cared for by the right people.

In the TCU, that meant providing a space for medically stable patients such as Monica, who have been deemed Alternate Level of Care (ALC), to prepare for discharge either to their community or a long-term care (LTC) setting while being given basic physical care and monitoring by Registered Practical Nurses and Personal Support workers.

Just over one year later, the 24-bed unit has been successful in saving the province more than 9,000 ALC days on acute care and rehab units, and has discharged 15 patients. To date, no patients have been re-admitted.

At first glance, the number may seem small. But consider the fact that the Bickle Centre provides complex continuing care (CCC) to patients with multiple medical needs, who may be participating in a slower stream of rehab.  Some patients in the TCU have spent, on average, three to four years ALC in the CCC setting, while waiting for an appropriate home setting or LTC. After arriving on the unit, these same patients were discharged within six to eight months.

"The TCU is part of a relief strategy that facilitates bed flow in acute care and acute rehab," says Marianne Ng, Clinical Manager.

"Our unique care model focuses on complex discharge planning. Everyone's roles are tied to that, and everything we do for a patient is approached through that lens."

The TCU difference: a focus on complex discharges

A patient's time on the TCU is generally spent working with the team on optimization strategies and addressing barriers to discharge, such as diabetes management and behavioural issues, in order to meet LTC criteria. 

Monica spends her time strengthening her independence, so she can one day move into an accessible apartment, where her care will be supplemented by teams in the community.

"I spend time in the kitchen, do laundry, and I'm practicing new ways to dress myself and perform self-care from my wheelchair," she says.

This patient-centred approach is taken right up to discharge, and beyond. 

"We've noticed a huge gap in the actual transition process, and sometimes, sending someone to long-term care with a piece of paper just doesn't do them justice," says Lisa Carrington, discharge coordinator, TCU.

As much as possible, Lisa escorts patients to their new home and helps ensure a smooth transition. She makes sure the home has a clear understanding of who the individual is, and what their needs are – right down to their hobbies and food preferences.

"It can be a very emotional transition for patients," says Lisa. "Bringing us along comforts the patient, comforts the home, and bridges that gap.

"It makes all the difference."

Keeping patients safe with STAR

A key piece of complex discharge planning involves ensuring a patient's medical condition remains stable. That, and ensuring safety remains a priority, is why the team implemented "Stop, Think, Act, Review (STAR)" rounds.

Every day at 11:20 a.m., they come together for a five-to-10-minute huddle to review each patient's care needs, using "looking back, looking forward" language, and ask for help.

This simple step allows the team to get ahead of any issues before they become a bigger problem.

"If we see a patient with a new pressure injury, we're able to flag it to the team earlier in the day, to ensure appropriate actions are taken in a timely manner," explains Cheng Wen, RPN on the unit.

"Otherwise, the morning gets busy, giving showers, meals, and personal care, and it may not get documented until the afternoon. By then, it's more difficult to get a same-day consult."

The TCU team agrees that the most exciting part of their journey has been drawing on their interprofessional knowledge to implement new care models and processes that put patients first, while supporting the needs of the larger healthcare system.

While admission to the TCU prioritizes UHN patients, the team reviews referrals from anywhere within the Toronto Central Local Health Integration Network, or TC-LHIN. ​

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