Restoring and reactivating – The ‘Stepping Stone’ to independence at home

Tony DeCaria was admitted to the Restorative and Reactivation program (R&R) at Markham Stouffville Hospital in November of last year after recovering from an acute illness. In order to discharge him home without difficulty, he required some additional rehabilitation and restoration to return to his optimal level of well-being.

Since being discharged in January, he has managed at home without additional supports, and has been able to maintain independence. “The R&R team felt like a family, I got a lot of information from them on what to continue doing when I got home,” says Mr. DeCaria. The program, launched in May 2010, has one simple goal: give patients the skills to live healthy, independent lives at home. B

y working closely with the team, and through their participation in groups, patients develop a sense of empowerment and well-being that helps them when they are discharged. “The ideal candidate for this program is someone who has been in the hospital recovering from a fairly serious illness or injury,” explains Julie Sullivan, director of the medical services program at Markham Stouffville Hospital. “They don’t need acute care anymore, but need some extra strengthening and support before they can return home. This program acts as that stepping stone.”

Cooking classes, dancing, and movie nights are usually not what you think of when you think of a hospital but those very things are helping to get patients up, moving and returning to live independently. The R&R program is made up of 15 beds and offers specialized services from various health-care disciplines to support older adult clients in developing the necessary skills to continue to function as independently as possible at home and in the community using a holistic approach to patient care. By addressing the physical, social, emotional, cognitive and spiritual needs of each client, the program focuses on complete wellness for each patient upon discharge.

When a patient arrives on the unit, they receive an informational folder outlining the expectations as well as anticipated outcomes of the program. The program is a partnership between the patients and the hospital and each play an important role in its success. “We need the patients to be interested and engaged and we need to offer them a program that works for them,” says Zelda Fonariov, patient flow coordinator for the program. “This really is a true partnership and we are all benefiting from its success.”

For the patients and the program to be successful, it is important to set a precedent of active participation from the beginning, as patients are expected to play a role in their recovery. By considering the goals, needs and interests of each patient, the R&R team is better able to plan and implement interventions, as well as ensure the best possible patient outcomes for discharge.

The R&R team is a dynamic group, made up of physiotherapists, occupational therapists, therapeutic recreation specialists, rehabilitation assistants, nurses, physicians and patient flow coordinators, among many others. “Each member of the team has a very important role,” says Sullivan. “From assessing the needs and goals of the patient, to teaching patients new ways of doing things in their homes – the whole team works together to ensure each patient’s treatment is individualized and will help meet the long-term goal of returning to their own home.” After the initial meeting with the team, the real work – and rehabilitation – begins.

Patients of the program participate in two 30-minute therapy sessions per day. This includes group therapy participation such as Tai Chi, as well as one-on-one intervention from members of the health-care team. Patients are encouraged to participate regularly in therapy not only to develop a routine of increased activity level, but also to prepare for their personal care and leisure routine at home. “The best part of this program is the patients,” says Nicole Pilon, rehabilitation assistant. “They are truly motivated to be here and to get back to living on their own. They have embraced this program and, in many cases, exceeded our expectations.”

Patients’ physical health is often the determining factor for how quickly they recover, so exercise and fitness focus groups are available six days a week. The groups have also been designed for different levels of ability and range in focus from working on balance, strengthening, resistance training, endurance and cardiovascular fitness, to offering patients at any level of ability the opportunity to engage in physical activity. Physical wellness is not the only goal of this program. Social, emotional, mental and spiritual wellness is also promoted by the R&R team through recreation based groups throughout the week, as well as through one-on-one intervention.

Culinary, relaxation, music and non-denominational faith groups allow patients to achieve optimal wellness in all spheres of life. To date, the program has discharged 75 per cent of patients home, and 80 per cent of these patients remained at home after three months post discharge. Although patients are given up to 60 days to complete the program, the average length of stay has been 32 days, as patients respond well to the structure and level of involvement from the R&R team. “This program is really a win-win situation,” says Sullivan. “The program keeps older adults out of long-term care by providing them with assistance in maintaining their independent living which helps to reduce the overall strain on health care brought on by an aging population.”