Complex Continuing Care Inpatient - St. Joseph's Care Group

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Complex Continuing Care, Geriatric Assessment, Hospice Care, Reactivation, Respite Care, Transition

Complex Continuing Care (Top)	Location: {Hospital} Contact: {Terri}

Referral Process:

Referrals to the service are initiated through the Community Care Access Centre at 807.345.7339

Costs Involved:

The Ontario Health Insurance Plan (OHIP) covers the cost of your hospital care. You will be responsible for the monthly chronic care bed co-payment fee.

Speech Language Pathologist

The Complex Continuing Care Service is a comprehensive inpatient program designed for persons over the age of eighteen with complex health care needs. The program is most suitable for persons with medically unstable but chronic conditions, ie., those persons requiring frequent laboratory services, diagnostic, respiratory, life-supporting medical and nursing interventions. The program of care incorporates assessment, treatment, supportive care, and palliation. Program participants will be assisted to achieve and maintain their maximum potential for health and ability. The program will provide medical management, skilled nursing care and a range of interdisciplinary diagnostic and therapeutic services and technologies. The Complex Continuing Care Team will facilitate and/or assist whenever possible, the most appropriate placement outside the hospital when the client's goals have been achieved or their care needs can be met in another setting.

Admission Criteria

you have a chronic or progressive illness or disability
you are no longer able to live independently in your community
your care needs exceed those available through community services or in a nursing home
your medical condition is stable and your potential for improvement is limited

Team Members

Dietitian
Occupational Therapist
Spiritual Care Worker
Physiotherapist
Psychologist

Psychometrist
Physicians
Pharmacist
Registered Nurse
Registered Practical Nurse

Therapeutic Recreationist
Rehabilitation Assistants
Social Worker
Speech-Language Pathologist

Geriatric Assessment Beds (Top)	Location: {Hospital}

Referral Process:

client must be referred by a physician

Goal:

The goal of the Geriatric Assessment Beds Service is to have the client return home.

Dr. Bon and Nurse

The purpose of the Geriatric Assessment Beds In-Patient Service is to provide initial assessment for an individual who has experienced a decline in health or is experiencing difficulty coping at home.

The Geriatric Assessment Beds Service is an ASSESSMENT PROGRAM.

Assessment

During the two week program, a team of health care professionals will assess the client and recommend interventions which allow the client to return home.

If the client is unable to return home after the two weeks, recommendations may include:

transfer to a Transition bed for further treatment
a referral to the Reactivation Service

Team Members

Geriatrician
Nurse Practitioner
Registered Nurse
Registered Practical Nurse
Physiotherapist

Occupational Therapist
Social Worker
Rehabilitation Assistant
Psychologist
Psychometrist

Admission/ Discharge/ Transfer Planner
Dietitian
Spiritual Care Worker
Speech-Language Pathologist
Therapeutic Recreationist

Hospice Care (Top)	Location: {Hospital} Contact: {Terri} and {Marianne}

Referral Process:

Admission is by physician referral

Family visiting

The Hospice Care Service at St. Joseph's Hospital is designed to provide care with compassion and concern, based on the Judeo-Christian tradition, for individuals and their families facing terminal illness, at a time when the goal is not a cure. The emphasis of palliative care is on the control of pain and symptoms, in order to maximize the quality of life by addressing physical, emotional, social, cultural and spiritual needs. It is multidisciplinary in its approach and its scope and extends to include grief and bereavement.

Admission Criteria

Need for pain and symptom management
Need for family relief (which is a temporary admission to allow families to recuperate)
Need for terminal care

Team Members

Dietitian
Occupational Therapist
Music Therapist
Physicians

Physiotherapist
Spiritual Care Worker
Pharmacist
Registered Nurse

Registered Practical Nurse
Therapeutic Recreationist
Social Worker
Speech-Language Pathologist

Reactivation (Top)	Location: {Hospital}

Referral Process:

client must be referred by a physician

The Reactivation Service is located on the 2nd Floor of St. Joseph's Hospital. The Reactivation Service is a 20 bed in-patient rehabilitative program designed for older individuals who have experienced a recent decline in their independent functions due to progressive debilitation and/or physical deconditioning.

Occupational Therapist

The service addresses the needs of individuals whose clinical and/or social problems prevent them from coping adequately with the demands and activities of daily living in their own homes.

The main goal of the multidisciplinary team is to help improve the client's ability to live independently and to exercise control over the quality of their health and everyday activities. The client will also learn to use resources and support services in the community.

A team of health care professionals will do a comprehensive assessment of the client's health status and develop a rehabilitation program to meet client's individual needs. The program is usually in excess of two weeks. The client's individual rehabilitative requirements may range from slow-paced rehabilitation to intense, short-term rehabilitation. The team works with the client and client's family to develop realistic and useful goals.

Family and friends are a valuable part of the client's social network. The team encourages them to be active in client's daily routine. Visiting hours are flexible. Family and friends are welcome to visit anytime as long as it does not interfere with client's designated therapy time.

Admission Criteria

Discharge Criteria

client must be over 60 years of age
client is deconditioned by inactivity or medical setback
client is medically stable
client is able to follow instructions
client is able to respond to rehabilitation and participate in their program
client must have the desire and motivation to participate in the program
client must have a sufficient degree of mobility, strength and cognition to actively participate in their transfers
client must have the potential to be discharged home/ back to the community

treatment goals have been achieved
client has reached his/her maximum functional potential
client desires to leave the program
client's condition becomes unstable

Reactivation Team

Dietitian
Occupational Therapist
Physiotherapist
Psychologist
Psychometrist

Physician
Pharmacist
Spiritual Care Worker
Registered Nurse
Registered Practical Nurse

Recreationist
Rehabilitation Assistants
Social Worker
Speech-Language Pathologist

Respite Care (Top)	Location: {Hospital}

Provides short term relief and respite for families/ caregivers who are providing continuing care for disabled or chronically ill family members in the community.

Transition (Top)	Location: {Hospital}

Referral Process:

client must be referred by a physician

Margaret and Sherry

The Transition Service is located on the 5th Floor of St. Joseph's Hospital. The Transition Service is for clients who no longer require acute hospital in-patient services, but who are not ready for discharge home and/or are awaiting supportive/ rehabilitative services.

The uniqueness of Transition is that people do not remain on Transition for long periods of time, but move onward to other areas such as their homes, other services or long term care placement.

Visiting hours on the Transition Service are flexible. Family members are welcome to visit at any time.

Admission Criteria

Discharge Criteria

Discharge Options

client must be an adult
client is no longer considered to need acute care
client must require ongoing treatment from one or more professional staff

(Clients must meet all criteria)

client is transferred to another hospital service, home or long term care
treatment goals have been met
client has reached maximum potential
client condition worsens and requires acute care

(Clients must meet all criteria)

community
other St. Joseph's Hospital service
long term care / complex continuing care
acute care

Transition/ Subacute Team

Other Services Available

Admission/ Discharge/ Transfer Planner
Clerk Typist
Dietitian
Occupational Therapist
Physiotherapist

Spiritual Care Provider
Psychologist
Psychometrist
Registered Nurse
Registered Practical Nurse

Rehabilitation Assistant
Social Worker
Speech-Language Pathologist
Therapeutic Recreationist
Volunteers

Audiologist
Chiropodist
Pharmacist
Enterostomal Therapist