4. System Transformations: Building a Regional System of Reintegration Programs to Support Transition of ALC Patients into the Community (Panel)

This presentation will discuss key learnings arising from a current pilot project under way in the Toronto Central LHIN that is testing the implementation of Reintegration Care Models (RCMs) focused on supporting the transition of ALC patients from hospital. Fourteen organizations received funding (CSS, hospitals and long term care) to test a number of different types of reintegration units (clinical care and personal care units as well as a range of respite services). This topic address the S in the LEADS framework – Systems transformations, as an important new care delivery model aimed at systemic change.

This presentations will discuss the momentum behind designing a regional system of reintegration care models to facilitate the transition of patients from hospital. The discussion will reflect on the impact of the RCM investment as a local, innovative solution that leverages existing partnerships with community providers and utilizes existing capacity within the community to reduce ALC pressures. The presentation will reflect on challenges, successes and lessons learned by some of the fourteen partners involved in the project.

As with any new innovation, appropriate time is required to assess the actual impact of the change process. However, initial findings arising from the RCMs pilot are encouraging and are validating the value of RCMs. Outcomes that will be discussed include: the increase in awareness of RCU programs, the steady rate of referrals to RCUs, majority of clients transitioning through the RCUs within specific LOS targets, and the impact of transitions to RCUs on the hospital ALC rate (ALC days saved).

By the end of this presentation, delegates will learn about some of the successes and challenges of community organizations participating in the pilot project, as well as the contribution that RCMs are making to support the transition of ALC clients from hospital.  Participants will have a better understanding of how the model can work as a collaborative effort, appropriateness of the various models, capacity and right sizing, standards to support sustainability of the program, and how to scale and spread and raise awareness of RCMs as a new level of care.


Debra Walko – LOFT Community Services

Beverley J Nickoloff – Reintegration Care Project

Lori Holloway – Bellwoods Centres for Community Living





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