Enabling people with complex care needs to transition out of hospital

Partnerships with long-term care

Location: Ottawa Hospital, Ottawa, ON

Across Canada, attention has turned to capacity challenges in hospitals and our health system. With wait lists for many health services under pressure, it is not uncommon for patients to wait in hospital for weeks or months before moving to the care destination most suited to their needs.  

Ontario’s long-term care home wait list is currently  more than 45,000 people for approximately  76,000 spaces – and the wait list is growing. This lack of capacity creates pressures across the system: in Ontario hospitals, for example, in 2021/22 approximately 40% of all hospital alternate-level-of-care (ALC) patients are waiting for long-term care. 

Transitional care approaches provide a missing link in the health care system and are becoming more common across Canada, through a variety of different models of care and governance. Two standout examples of these collaborations are the partnerships between The Ottawa Hospital and Extendicare, and Schlegel Villages with hospitals in Mississauga. 

The Ottawa Hospital and Extendicare: A Transitional Care Unit Model 

In 2021, The Ottawa Hospital and Extendicare launched a joint transitional care unit within Extendicare’s West End Villa long-term care home. This innovative approach provides a much-needed bridge between hospital care and community-based long-term care. The unit initially opened with 55 beds, offering a more suitable environment for seniors with complex needs who no longer require acute hospital care but still need support to regain independence. 

Staff from both The Ottawa Hospital and Extendicare collaborate in this model, with Extendicare providing daily care such as meals, housekeeping, and social activities, while hospital physicians and nurses manage the clinical care of patients. This integrated approach has since expanded to 100 beds, significantly reducing the strain on hospital capacity while offering a more appropriate setting for patients’ recovery and care. 

Schlegel Villages and the Enhanced Supportive Neighbourhood (ESN) Model 

Schlegel Villages launched the Enhanced Supportive Neighbourhood (ESN) model at Erin Mills Lodge in Mississauga in 2021, designed to care for ALC patients who experience frequent or “severe” behavioural expressions as a result of dementia, brain injury and/or mental health diagnoses.  It is historically difficult to find spaces for these complex patients in most conventional long-term care homes because of concerns about risk.  

Recognizing that this subset of ALC patients does not thrive in a hospital setting, this 20-bed pilot program provides a safe, supportive, and engaging environment, allowing patients to transition more smoothly into long-term care. The model is founded on relational care, where patients receive not just clinical support but a home-like environment, emotional and social engagement, with staff working 12-hour shifts to ensure continuity of care and deeper connections with residents. 

Key Takeaways for Health System Partners 

Both the Ottawa Hospital/Extendicare Transitional Care Unit and Schlegel Villages’ ESN model demonstrate how long-term care homes can play a critical role in supporting hospital capacity challenges by providing a more appropriate and cost-effective setting for ALC patients. These partnerships showcase several best practices that other health system partners can learn from: 

1. Integrated Care Models: Collaboration between hospitals and long-term care homes, where both clinical and daily living support are provided, creates a more holistic and patient-centered approach to transitional care. 
2. Relational Care: Fostering relationships between residents and staff, as seen in Schlegel Villages’ ESN model, leads to improved patient outcomes and reduced reliance on medications or restraints. 
3. Optimized Use of Resources: By transitioning ALC patients to more appropriate care settings, these models alleviate hospital capacity pressures and reduce healthcare costs. The Ottawa Hospital and Extendicare’s unit has shown a significant cost savings compared to prolonged hospital stays. 
4. Patient-Centered Environments: Both models prioritize creating a home-like atmosphere, which aids in the mental and physical recovery of residents. This personalized approach helps ease the transition out of hospital and into long-term care. 

Shaping the Future of Transitional Care 

The success of these programs signals the potential for broader implementation across Ontario and beyond. By focusing on partnerships with local long-term care homes, health system partners can reduce hospital bottlenecks and improve patient well-being. 

These programs are some of the examples shared in the Suggested Action Plan on How To Support Our Frail Elderly, on how our health system can better connect and bridge services for seniors in Ontario.