Hospital discharge liaison team eases transition for geriatric psychiatry patients into the community

“This place is like a palace,” said 78-year-old Alvin Locke six months ago of his new home in a London, Ontario long-term care facility. Alvin had recently moved from St. Joseph’s Regional Mental Health Care London (RMHC) where he had been a client of the hospital’s geriatric psychiatry program for 18 years. Today, with the transition period behind him and accustomed to the routine of his new residence, Alvin continues to call his home a palace.

No palace functions without a strong support system. For Alvin and others like him who have complex mental health care needs but no longer require hospitalization and are returning to the community to live in a long-term care setting, their support system is particularly unique. It centres on a discharge liaison team – the first of its kind in Ontario – developed a year ago through community investment funds provided by the Ministry of Health and Long-Term Care.

The discharge team is available 24 hours a day, seven days a week to assist clients, their families and other caregivers. With a combination of long-term care and psychiatric nursing experience, they are highly skilled in providing additional training and education to the long-term care home staff.

“The idea for this team evolved after reviewing some of the contributing factors that led to difficult transitions in the past,” says Bonnie Kotnik, director of the RMHC geriatric psychiatry program. “Now, with the individualized support and continuity of care the team provides, clients like Alvin are enjoying quality of life in a more normalized environment, and they are staying there.”

Alvin got off to a tremendous start in his new residence, participating in cooking and fitness classes, sing-alongs and bingos. Alanna O’Donnell, discharge team member and RN, was visiting him on a weekly basis at the outset.

“The move for Alvin was extremely positive,” says Alanna, “but after two months he began to relapse. The staff at the long-term care home were concerned, but because I knew Alvin so well, I was able to reassure them that this was typical for Alvin. My support must have helped because within a month, Alvin was back to his usual self and by four months only required bi-weekly visits. I now only schedule monthly visits although I am available to the staff whenever they need me.”

Implementation for this pilot project was designed in two phases. Phase one began last September with team development and training, and is wrapping up this month with 12 clients being managed in a variety of long-term care homes and 25 in-hospital patients who have met the program’s criteria but haven’t yet transitioned.

Phase two will allow the program to proceed at a manageable pace. It follows the announcement in April 2004 of Versa Care-Centre (VCC) Lambeth as the designated long-term care home for this initiative. Renovations have just been completed, and at a rate of two to three admissions per week, a total of 22 geriatric psychiatry clients will soon be residing in a unit specifically enhanced for this project.

“We are very excited to join RMHC in this innovative project,” says Joan Woodley, administrator of Versa Care Centre Lambeth. “Our staff already has substantial experience and success in serving the needs of residents with mental illness, and the additional support of the discharge team will help them provide the most appropriate individualized care.”

While a smooth transition for the geriatric psychiatry clients is the ultimate goal, a seamless process is equally as important for staff and current VCC Lambeth residents. In August, VCC Lambeth hosted a “meet and greet” social for the discharge team, organized an information session for their staff, and held an open house for families of loved ones currently living in the home to address any of their concerns.

As residents are admitted, the discharge team will hold regular and intensive orientation sessions for VCC Lambeth staff. Once clients stabilize, the frequency of visits can decrease, allowing for potential future growth of the project.

Already expansion is planned for 2006, when VCC Lambeth will be moving to its new much-anticipated state-of-the-art home, with an increased number of beds for geriatric psychiatry residents.

While future clients of the discharge team will benefit from the enhanced resources at VCC Lambeth, those like Alvin who are already comfortable in other locations will continue to be cared for by the team. – A fine example of St. Joseph’s Health Care London moving forward in the vision for mental health care in Southwestern Ontario for treatment and support where and when people need it.