Extra help on the road to recovery

Before Randy Smith could start his life again following a double lung transplant, he needed special help along the way. His surgery had been a great success, but a post-operative complication left him in a coma for several weeks. When he arrived last November at St. John’s Rehab Hospital in Toronto after discharge from intensive care, he had lost a lot of strength and was anxious about what his future would hold.

“I could barely move at all,” he recalls. “I couldn’t even lift my arm.” After five days working with his multidisciplinary rehab team, he was standing with minimal assistance. For the first time in many weeks he took a few steps while his wife Kate looked on. “It’s unbelievable!” he enthused. The prospect of spending Christmas at home with his wife and son was no longer a dream.

What made the difference for Randy was a smooth transition directly from acute care to Canada’s first dedicated inpatient rehabilitation program for organ transplant recipients. St. John’s Rehab developed the program in 2004 in partnership with the Multi-Organ Transplant program (MOT) at Toronto General Hospital, University Health Network (TGH, UHN).

Transplant patients can require specialized rehab because of factors such as a lengthy illness prior to surgery, a suppressed immune system because of drugs that inhibit organ rejection, respiratory problems, loss of muscle mass and the challenge of managing a complex mix of medications. “Our goal is to achieve better patient outcomes,” says Malcolm Moffat, President and CEO of St. John’s Rehab Hospital. “The integrated care we provide through this partnership with University Health Network will allow people recovering from organ transplant surgery to make a smoother transition back to good health, so they can return to their home and family as soon as possible, and regain their independence and quality of life.”

The idea behind the program is simple: to ensure patients get the right care in the right place at the right time. On arrival, Randy met his multidisciplinary team to set his rehabilitation goals. The team then customized a program of services to allow Randy to meet those goals. St. John’s Rehab provides six inpatient beds for the program, which will serve up to 60 inpatients per year, as well as comprehensive outpatient services to educate, monitor and support transplant recipients.

St. John’s Rehab uses a ‘whole person’ approach to rehabilitation care by bringing a complementary mix of health care professionals together on one team to serve not only the patient’s physical needs but their psychological and emotional needs as well. So a rehab team may include physiatrists (specialists in physical medicine), nurses, doctors, physiotherapists, occupational therapists, pharmacists, dieticians, psychologists, social workers and one of the Sisters of St. John the Divine. The Sisters, who founded the Hospital in 1937, are still involved as members of the rehab teams providing spiritual care in a multi-faith, multicultural environment.

By preparing an intensive program of therapy and support, the staff at St. John’s Rehab helped Randy recover his physical strength, learn to manage his medication, and understand the emotional challenges and lifestyle changes necessary to adjust to his new life. This kind of comprehensive rehab can be critically important for patients who have complex medical needs and who have had a lengthy stay in intensive care following transplant surgery.

Dr. Gary Levy, Medical Director of UHN’s Multi-Organ Transplant Program, says as a result of the new rehabilitation program, organ transplant care will improve and health care dollars will go farther. “This initiative will allow for a seamless transition of care through the collaboration of health care professionals who are world renowned for their expertise in rehabilitation medicine and in the field of organ transplantation. This will help us provide better care for patients and increase access to transplantation. In combination with the care provided at St. John’s Rehab, patient outcomes will be improved.”

Moffat said acute care and rehab experts at both hospitals will enhance the program by using video conference “telehealth” technology. This year the NORTH Network approved St. John’s Rehab as a patient site. This means a transplant inpatient at St. John’s Rehab can have a consultation with their acute care specialist without having to travel from one hospital to another. Moffat expects the integration of care between the two facilities will lead to more collaboration in future on research and education initiatives.