Guy in wheelchair with PSW
"I'm working my way back to doing things I used to. I'm ready now, for what comes next," says ALC patient Mike McKinnon, pictured here with personal support worker Tenzin Dechung. (Photo: UHN)

On Toronto Rehab's North 3-Transitional Care Unit (TCU), located at Bickle Centre, Friday morning karaoke dance parties get patients up and moving; activation and wellness activities recondition bodies and minds, following a stay in acute care; and individuals such as Mike McKinnon break down barriers that stand in the way of a safe discharge to the community.

"They brought the breath of life back into me," says Mike, whose initial struggle accepting his new normal, following heart failure, left him unmotivated to get out of his hospital bed and exhibiting responsive behaviours such as lashing out towards others.

"I thought it was over for me, but after being here, I feel 100 percent different now," he says. "I've formed relationships, I get up and around, and I'm working my way back to doing things I used to.

"I'm ready for what comes next."

Mike's story is a reflection of what is possible, when the right patient receives the right care, in the right place. That place is the North 3-TCU, where more than 100 patients have received care since it opened in late April of last year.

Enhancing flow within our hospitals

When the unit opened its doors during the first wave of COVID-19, the goal was simple: create a space where Alternative Level of Care (ALC) patients can go, in order to support flow in acute care and ensure beds are available to those who need them most.

ALC patients are medically stable, but aren't quite ready for discharge. They may need support carrying out activities of daily living, more time to strengthen their bodies after a prolonged hospital stay, or are waiting for placement in LTC or another assistive living environment.

"The opening of the North 3-TCU, along with our sister unit, North 5-TCU (also at Bickle), ensures that ALC patients receive the care they require and are supported to transition to the community or LTC," says Margaret (Meg) Quesnelle, Program Manager for North 3-TCU.

Matching patient need to professional scope

To that end, part of what sets North 3 apart is that the nursing care is provided by registered practical nurses (RPNs) who work to full scope of practice.

They, along with personal support workers (PSWs), healthcare assistants, allied health professionals, provide the basic but complex care ALC patients require. This includes medication administration, health assessments, and wound care.

"We established, from the get-go, that RPNs have the knowledge, skills and judgment provide the complex nursing required," says Meg.

"At the same time, we wanted to further empower them, by expanding their expertise.

"We knew that we would increase quality of life for patients and bring efficiency to the system if RPNs learned how to perform some traditionally acute-care procedures, such as flushing and taking blood from port-a-caths, that our complex ALC patients required."

The North 3 Transitional Care unit
The North 3-Transitional Care unit is led by registered practical nurses (RPNs), who, along with personal support workers, healthcare assistants, and allied health professionals, provide the care ALC patients require. (Photo: UHN)

Secure in the confidence and support of leadership, RPNs have risen to this elevated level of responsibility.

"Being more responsive to the acuity of patients has definitely helped deepen their trust in us," says Sarah Joseph, an RPN on the unit.

"It also exciting to be able to increase our competencies, and become more prominent in the workforce."

Overcoming behavioural barriers to discharge

But care on the unit extends far beyond meeting physical needs.

Because responsive behaviours are a common barrier to LTC admission, especially among patients with dementia, staff are committed to finding solutions that keep patients safely moving through the system.

"We take the time to understand what may be triggering certain behaviours, and try to address their biopsychosocial needs as best we can," says Naomi Sutcliffe, the social worker on the unit.

"This sets them up for success, both while they're here, and wherever their next destination may be."

Mike had spent years living mainly off the grid, when his health started to decline and he found himself in the hospital. Bed-bound and feeling trapped, when he first arrived on the unit, he would lash out to the point where he couldn't have a roommate, and staff were cautious when approaching him.

Sara Gies, a mental health clinician in UHN's Behaviour Support Specialist Program, consults on the unit once per week. In this role, Sara provided the team with an individualized behavioural assessment and treatment plan that assisted the team in meeting Mike where he was, using client specific tools and strategies.

For example, the team learned that taking time to build rapport, setting and respecting clear boundaries, being quick and efficient in their care provision, and using sports analogies, all helped build Mike's trust and improve his quality of life.

When Mike is ready to move on from Bickle Centre to his next destination, Sara will provide transition support, in part, by sharing the behavioural care plan with the receiving team, to ensure continuity of care.

"Staff didn't personalize Mike's early behaviour – we worked with Sara and Mike's family to understand the 'why,' behind it," says Naomi.

"We were able to come up with ways of providing care that was well received by Mike, safe for staff, and that will ultimately help him gain admission into LTC."

Today, the team says they no longer need to flag any current behavioural concerns to Mike's next healthcare team, because they don't exist anymore.

According to Naomi, the real Mike is a kind and friendly guy. But he's quick to return the compliment.

"I came in with an attitude of indifference and intolerance, but staff understand me, and listen to what I have to say," says Mike.

"Everyone here is so kind, and have shown me that there is life after being sick."

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