Now that spring has officially sprung, Bryan Hewitt spends his days enjoying the fresh outdoors and rebuilding his strength following his stay at Providence Transitional Care Centre (PTCC) and experiencing very positive health outcomes resulting from the Providence Care Transitions Home pilot program.
Ontario Health funding led to the creation of this extremely well-received and successful PTCC pilot program. Its goal was to improve a patient’s continuity of care by extending therapy services from the hospital into the community. The innovative home care pilot program ran from January to April of this year, effectively bridging a gap in our regional healthcare system by creating new opportunities for a seamless and safe transition home. While enhancing the overall patient and family experience, the pilot program also reduced the length of stay in the hospital by an average of 59 days.
Although the pilot was in place for only a short time due to funding limitations, it had significant impact. A total of 24 patients, ranging in age from 64 to 98, got home sooner and were supported and cared for at home primarily by the same team of allied healthcare professionals, including physiotherapists, recreational therapists, social workers, dietitians and speech language pathologists, they relied upon in the hospital.
“I feel this particular program is absolutely necessary for a good outcome. From a patient’s point of view, it’s critical. This program gave me assurance that I was going to have full support once I got back home. It made me much more at ease knowing that I didn’t have to spend any further time in a hospital setting,” says Bryan.
On Christmas morning last year, Bryan became a candidate for the pilot program after his thoughtful holiday gesture toward a delivery driver resulted in a terrible fall in his driveway. He broke his femur (thigh bone) completely, which is the longest and strongest bone in the body. To complicate matters, the broken femur was on the same side as a previously replaced hip. Bryan received strict orders from his surgeon to not weight-bear for six weeks.
As Bryan recovered at PTCC, it was clear to the Charge Nurse – who played an important role in the pilot’s success by assessing patients and completing referrals – that Bryan was a perfect candidate. They brought the inter-professional care team together by coordinating schedules, as well as anticipating and overseeing what services and resources Bryan would need to get home safely.
“Identifying and assessing patients who would benefit from this new program and coordinating their care meant better outcomes and an even smoother continuity of care for them. With patients’ skills and confidence built up at PTCC, we knew their recovery would be even more successful at home with a team they were already familiar and comfortable with – a team who knew and supported their unique journey,” says Jessica Almeida, Charge Nurse at PTCC. “We are always looking for more ways to bridge the gaps in healthcare, alleviating the strain on regional hospitals, while helping older adults age well at home.”
So, after nursing staff completed Bryan’s referral, physiotherapist Brittany Gungor continued providing care in Bryan’s home after he was discharged from the hospital – the very day he arrived – which is a unique feature of the pilot program.“Patients like Bryan were so appreciative to have these services in place as soon as they got home. Going home can be so overwhelming. This important continuum of care made a huge difference in patients’ recovery journeys and was very comforting for everyone involved,” explains Brittany.
Bryan’s in-home care included specific exercises to continue building strength, learning proper techniques for walking, utilizing appropriate equipment to further his recovery and helping to identify any risks at his home that could lead to another fall. Brittany was also only a phone call away in between appointments to answer any of Bryan’s or his wife Oksana’s questions.“Brittany was so encouraging. Knowing I could call her anytime inspired me to be diligent about my recovery. I felt more confident by having the proper knowledge. In many ways, I didn’t want to fail because Brittany was so invested in my recovery. The personal connection we built is something many people desperately want when faced with this situation,” says Bryan.
The pilot enabled allied healthcare professionals to provide care in patients’ homes or retirement homes one to two times per week, for up to eight weeks. The dedication and hard work certainly paid off for Bryan, who was discharged one week early from the pilot program. He credits his success and smooth recovery to the pilot program and having Brittany available to share her expertise, encouragement and support.
“If this program wasn’t available, my outcome wouldn’t have been as good. Without it, I probably would have landed back in the hospital. Brittany gave me assurance that I was going to be okay at home and that I would get as much support and guidance here as I did during my hospital stay,” says Bryan.
“As a physiotherapist involved in the pilot program, my goal was to further patients’ skills and confidence that was built during their hospital stay. We are so grateful for the funding from Ontario Health for this pilot program. We truly established a program that has a strong foundation and can be transferrable and expand if and when the time comes,” says Brittany.
The funding for the pilot may have ended, but staff like Brittany say they are grateful to Ontario Health for the pilot experience and are hopeful for the future.
As for Bryan, he says he’ll miss his weekly appointments with Brittany but will continue to apply what he’s learned during his appointments into his everyday activities. An unfortunate fall provided him with a unique opportunity to recover though the Transitions Home pilot program.