Transitional Care

Transitional Care

Transitional Care supports adults to heal and rehabilitate in a non hospital setting in preparation to going home. It may be due to multiple chronic conditions, complex therapeutic regimes, recovery from surgery, stroke, acute injury, heart attack, hip or knee replacement, or other physical or functional impairments that are creating barriers to returning home.

Transitional Care provides a person-centered care approach to meet the unique medical and non-medical needs of our clients and their caregivers. We provide training/retraining to the client with strategies to maximize active participation, and functional independence in care and home tasks. We also offer bedside training, informal education, and formal education through group in-services to empower and support formal and informal caregivers. This is an important part of the process, as the caregivers will be supporting the client upon return home.

The average length of stay is 14-45 days.

The Care

Prior to admission, a nurse will conduct an assessment of your current health status, housing, social supports, and goals. During your stay, we will help you regain strength, restore function, and improve health through skilled care and rehabilitation services.

Our multidisciplinary team will create a personalized care plan with you that covers all aspects of your care, such as physical needs like exercises and mobility training, good nutrition, and an individualized and adequate medication regime. Robust discharge planning is unique to every client and may included things like any needed equipment, pre-home safety screening, meal planning, nurse home check-ins, and any follow-up appointments with physicians, physiotherapists, community resources, etc.

Checklist of Areas Reviewed for Discharge:

• Assistance with daily living such as showers, getting dressed, using the toilet, etc.

• Monitoring health status

• Setting up prescriptions at the pharmacy, and ensuring a plan for safe medication administration upon return home

• Planning and preparing meals

• Transportation to appointments

• Companionship

• Household chores and laundry

• Mobility

• Safe home check and falls prevention interventions

• Community resources

  Optional: Transition Home – This program is available for up to three months post-discharge from the Transitional Care Unit, and offers periodic home visits or scheduled phone contacts. The focus of these visits is to monitor your transition home, reducing health complications and re-hospitalization. The team will work with your other care providers to ensure that you receive the follow-up care you need once you return home. A team member can even accompany you to your first physician visit following discharge to your home if you would like this service.

Physical space

Transitional Care is provided in the Sunrise Community of Evergreen. This community has 20 single rooms offering a combination of transitional, respite and long-term care beds.

Each room is a single occupancy room with a small washroom and shower. The room is equipped with an electric bed, overhead ceiling lift, armoire, bedside table, dresser and TV with cable included. WIFI is complimentary. There is a common phone line that clients can use. Private use phones are the responsibility of the client.

There is also a bathing room with an accessible soaker tub, a living room and a small area with exercise equipment. Laundry is done on site. All clothing must be labeled on admission. We provide labeling for a one-time fee of $20.00.

There is a central kitchen serving nutritionally balanced, home-made meals to the 20 rooms on Sunrise.  Our chefs create individualized and flexible dietary plans to support you on your road to recovery, but also provides restorative care programs in meal preparation.

The Team

Nurses: Additional training and expertise in restorative care, surgery (general and orthopedic), stroke care, wound care, and medication management including IV therapy.

Health Care Assistants (HCA): Provide specialized restorative and rehabilitative care. Expertise in special handling skills such as sitting, standing, pivoting and ambulating (walking), as well as all personal grooming and hygiene.

Physical Therapy: Physical Therapy: Physiotherapist, Jen Fyfe, is the Care Leader for this program. Jen oversees the care planning to help you regain your independence in mobility, symptom management, safety, and maximizing rehab potential with exercise and education.

Occupational Therapy: Occupational therapists provide assistance and education to help you re-establish your daily routine in areas like bathing and dressing. Evergreen’s Occupational Therapist provides coaching and mentorship to the team on integrating restorative opportunities into all aspects of care.

Discharge Planners: Members of the multi-disciplinary team plan and support smooth transitions between levels of care.

Costs

Once you are accepted for admission, and reach the first spot on the waitlist, a $500 deposit is required. This is when the multidisciplinary care planning begins. A cancellation policy is in effect.

Once the bed is available, the daily rate of $375.00 begins. An average stay of 14 days would cost $5250.

*Additional charges may apply