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Barbara's Safe Transition Home

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After a fall that kept Barbara in hospital, returning home wasn’t thought to be possible at first if she didn’t have 24 hour supervision. Her daughter Alison recalls, “There were safety concerns, but our family knows mom is fairly independent and would get better with supports to live at home.” Kathryn, Barbara’s Care Coordinator, understood the complexities of Barbara’s care needs and potential risks of going home, and co-created an individualized care plan unique to Barbara’s needs, with her, her daughters, Alison, Lee-Anne and Lynda, and all members of the care team. The care plan supported her safe transition home with a visit from a CCAC Rapid Response Nurse, and wrap around care coordinated to bring care into Barbara’s home and to connect her to community support programs.

Today, Barbara is managing well at home with personal support, is closely connected to her Care Coordinator, accesses community resources and has a lifeline in case of a fall. “Mom is still a little weak,” says Alison. “She builds her strength up by going to a seniors exercise program Wednesdays, and Thursdays she goes to the VON adult day program. Mom wasn’t on the right medications. Now she’s stabilized, doing great and connected to a mental health specialist. Sometimes the medications make her groggy, but she’s responsible in taking her medications. The blister packs help.”

When asked about the value of care coordinated for her mom, Alison shares, “I really appreciate Kathryn’s help in getting mom back on her feet and allowing her to be independent in her own home. Supports can teach mom how to be independent. How to be safe. It was such a relief to our family when mom got home from hospital and had CCAC care in the morning to get her dressed and ready for the day, along with dinner and nightly supports with medication checks. I think she will do well over time. Mom will need supports throughout her senior years. I hope when I am mom’s age, similar supports will be there for my sisters and I as we grow older together.”

 

Key Facts Icon - Website.jpg​Over 3,600 patients with complex needs received care in their home; 10% more patients than the previous year.

88% of patients referred for personal support from hospital received care within 5 days or less. For additional information, see our Wait Time/Wait List Information (updated monthly).

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