Transitioning from hospital to long-term care

By Tini Le

The decision to move into long-term care can bring mixed emotions; perhaps concern at leaving the familiar, alongside relief knowing 24/7 care will be on-hand. It’s the guidance and support of Home and Community Care Support Services care coordinators that help make this process less stressful for patients and families. 

Long-term care admissions across Ontario are facilitated by Home and Community Care Support Services, and the care coordination team plays a key role in supporting patients with the application, waitlist management and placement process. Care coordinators assesses applicants for eligibility and work one-on-one with patients, or their substitute decision maker, to select homes that meet their needs and preferences and provide a personalized approach to care. 

One year ago, the Bill 7, More Beds, Better Care Act 2022 was implemented, and amendments were made to the Fixing the Long-Term Care Act, 2021, to facilitate the safe transition of patients who no longer require treatment in hospitals to care arrangements in a long-term care home, while they wait for their preferred long-term care home. 

These changes shone a light on the dedicated and tireless work of Home and Community Care Support Services while bringing renewed attention to the patient-centred services and empathy care coordinators provide. 

“Our goal is to support people to get to a place where they are thriving,” said Home and Community Care Support Services Krista Brock, a Hospital Care Coordinator. “We are continually engaging patients and their substitute decision maker to make the best care decisions for themselves or their loved ones.”

Brock said the first challenge of the new legislation was helping patients and families understand what Bill 7 really entailed and helping them look beyond some of the media headlines.

“The legislation is not just about picking a home within a certain radius, it’s about an individual patient’s needs. And we will always strive to work with the patient or their substitute decision maker to obtain consent,” Brock said, adding one of her goals was removing fear from conversations and helping patients and families navigate information to make the best care decisions. 

“A valuable part of patient counselling is sharing specific details – including shorter waitlists – on homes that the patient or their family may not even know about and making clear that the applicant can continue to wait for their preferred home if they accept one of the other homes,” she said. 

To prepare for the new legislation, care coordinators received technical education as well as ethics training and interactive scenario-based coaching, guiding them on how to continue a personalized approach to care as part of a larger health care system. 

Abraham Balachandran, another Hospital Care Coordinator with Home and Community Care Support Services, said that the extensive technical and ethics-based training was instrumental in not just enabling him to explain the new procedures, but also having patients and families understand and trust the process.

“We play an important role in the long-term care admission process. Last year’s changes escalated and enhanced that role,” he said. “It’s important that we’re meeting individual health care needs and preferences along with professional responsibility and accountability to ensure the right care at the right place”.  

Last year, Home and Community Care Support Services helped over 28,000 people transition to a long-term care home. 

Tini Le is the Vice President, Patient Services, Home and Community Care Support Services Central and Toronto Central, Central Region Lead and Provincial Placement Lead.