When 72-year-old Mary Gariffe left Providence Care’s Providence Transitional Care Centre and returned home it came with equal parts excitement and worry.
“I was excited to get home but I quite liked it there [Providence Transitional Care Centre]. Everybody worked towards the common goal of getting me home and I enjoyed the program too.”
However once home, Mary’s programming, care and services didn’t stop. As a patient of Providence Care’s Transitions Home program, Mary has allied health therapists from the hospital care for her, but now in her own home.
“Mary gets the full spectrum of the therapies offered through the Transitions Home program,” says Occupational Therapist Lexi Bulak. “So that’s social work, occupational therapy, physiotherapy and recreational therapy; these are the focus of our team.”
Mary is recovering from a fall last year that left her with a torn quadricep. After three surgeries she entered Providence Transitional Care Centre to rebuild strength in her legs and regain knee motion and function. Now home, Mary works with her therapists to help make the transition home smooth and successful. In physiotherapy sessions she works on using her walker to get around her two-storey home and neighbourhood. Occupational therapy helps Mary with daily tasks of living, like feeding her cat and three dogs, while social work sessions support the emotional journey of her injury and her changing family dynamic. Recreational therapy is what Mary says she really enjoys. It encourages her to explore lost or forgotten hobbies, while also getting her involved with community activities and events.
“I’m really happy to see everybody and I always know who I’m opening my door to. I have goals to start sleeping on the second floor again and recreation therapy has helped sign me up for the Seniors Association to get involved in activities. You know, eventually the program will end for me and it’s sad. I look forward to the company and it’s been so helpful,” explains Mary.
Innovative Program
The Transitions Home program is available to patients and clients discharged from Providence Transitional Care Centre and Providence Care Hospital. Care is individualized based on need. Since Transitions Home became a fully funded program in November 2023, more than 200 individuals have received therapy in their homes.
“What makes our programming so unique, separate from other programs, is that our team sees our patients and clients in hospital, whenever possible, before they go home,” says Clinical Program Coordinating Supervisor for the Transitions Home program, Sheryl Gibson.
“So, our patients have a face, a name and a written care plan with an initial appointment date within 24 to 48 hours of discharge; they know what to expect and who to expect before they even get home. There is often an anxiety of the unknown when people are preparing for discharge. We’ve had a lot of positive feedback that people enjoy meeting their therapists beforehand and knowing that someone will be in their home within 24-48 hours of their discharge,” adds Sheryl.
Not everyone in the program receives all four therapies like Mary; care is specifically designed for the individual receiving it. Length of stay in the program is also dependent on the individual’s needs and requirements and is set to maximize independence and safety.
“Some people are referred to us because they are really anxious about going home and once our therapists get them set up, they realize they are good and able to manage. Other individuals may need longer term support to increase independence and mobility, such as through physiotherapy, working on stair climbing and rebuilding strength. We also support and assess with any equipment a person might need to navigate their home, like a wheelchair or a walker.”
What also makes the Transitions Home program so unique is the team approach to care. Therapists are always communicating with one another about the patients in the program and their progress, building off one another’s sessions.
“We have a team approach across all four disciplines within the hospital and also in the community which is very beneficial,” says Sheryl. “Our staff know what has happened in hospital before the patient gets home and once home, our team is always communicating with one another. They call each other multiple times per day, they go and do joint visits sometimes. Social work and occupational therapy (OT) might go together because OT is going to be tackling something challenging so social work will be there at the same time to offer support. They bounce ideas off one another and figure out things together. They’re a team that knows one another well and work well together which is really resulting in success.”
“My sessions with the therapists always complement each other,” explains Mary. “There’s a steady flow and there doesn’t seem to be a division or separation between everybody or what I’m doing. Everything works together. I always feel like the therapists are talking to each other.”
As Mary works to fully transition to living on her own again, she says she’s focused on her mobility, balance and overall comfort and confidence in her own home. She hopes to continue building strength so she can walk unassisted and go up and down her stairs without anxiety.
“Every day is better than the one before and every day I get less afraid. I was terrified going upstairs, but I’m not afraid anymore. I’m building confidence and more or less talking myself into trying new things, while at the same time, balancing listening to my gut about how much I can take on at once.”
Embodying a commitment to comprehensive, continuous care, the Transitions Home program at Providence Care is supporting recovery and well-being at every step, bridging the gap in care. Patients like Mary are experiencing a seamless journey from hospital to home and are set up for success to live well. The Transitions Home program and the staff who work on the frontlines, traveling across the southeast region, are transforming transitions into smooth, supportive pathways for patients and their families.
