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Coming Home - Made Possible by Partnering for Better Care

Photo - Jarvis, CCAC patientWhen Jarvis took over his father's real estate business in 1955, he never imagined he would be faced with selling his own home to move to long term care. Yet, as Jarvis and his wife Linda began to notice problems with his memory, remaining at home seemed unmanageable.

They needed help. The health system swung into action when Linda called 911 to assist Jarvis after he had a fall at home. Jarvis found himself in an ambulance, on his way to Grand
River Hospital (GRH), where he was quickly assessed. It was identified that a medication interaction led to his disorientation and fall.

Immediately upon his admission to hospital, the hospital team and the Integrated Discharge Planner (staff shared by Grand River Hospital and the CCAC) began planning for a safe return home.

From Linda’s point of view she saw a team of professionals working quickly and effectively. “The nurses and doctors worked together to help Jarvis and gave us hope he would return safely home,” says Linda.

"Our Integrated Discharge planning process is a truly collaborative model that highlights the need for the acute and community sectors to be working side-by-side," says Malcolm Maxwell, CEO Grand River Hospital "There is no hand-off because the discharge planning has been a joint effort right from admission to hospital." The integrated position between CCAC and Grand River Hospital,ensures “one foot in the hospital and one foot in the community” – with the goal to help patients reclaim their independence – returning and restoring at home whenever possible.

As Jarvis’ condition stabilized, the CCAC worked with providers to coordinate an enhanced  plan for home care services to support Jarvis when he arrived at home. A wrap around service plan that could include up to 24 hrs./day was developed to ensure Jarvis could recuperate and return to independence. "He just needed someone to give him a chance – we
didn’t want him to go to long term care," Linda says.

Within just two weeks of discharge, Jarvis was improving and regaining his independence enough to be supported with normal levels of personal support. Jarvis' recovery was so successful that it wasn’t long before they decided the application to long-term care was
no longer needed. Linda credits the personal support workers from Bayshore Home Health for helping Jarvis achieve his independence goals. "It's like having a family member or friend stop by to help out every day," explains Linda, noting that Jarvis' care and wellbeing is a true  partnershipbetween Bayshore, CCAC, Linda, and Jarvis himself.

Within a few weeks Jarvis was ready to try a community Adult Day Program. In combination with ongoing support from the CCAC the support provides stimulation and socialization for Jarvis and caregiver respite for Linda.

Jarvis remains quite active around the house and goes for short walks outside most days. "I just don't know what we would have done without all the help from so many places," Linda says, "I can't put a price on the difference it has made. At this point I can confidently say we are home to stay.