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Reintegration Care Models – Centralized Referral Management

The Reintegration Care Models (RCM) being piloted in Toronto Central Local Health Integration Network (LHIN) are designed to support inpatients and their caregivers in the transition from hospitals to the community. These initiatives are needs based and time limited, and are being provided in partnership with 13 different Health Service Providers (HSP) in the community.

There are 2 categories of RCM programs initiated in Toronto Central LHIN:

Reintegration Care Units (RCU)

The Reintegration Care Units support patient transitions from the hospital to short-term transitional care units in the community that provide a safe and supportive place to help patients increase strength, mobility and endurance to support their transition home or into an alternative care setting. These community-based models of care enable patients to receive appropriate support and/or regain strength and independence outside of hospital.

These sites are all time-limited (varies per program) thus a plan for a discharge destination post-RCU is requested.  There are no fees for staying at each site but site may expect clients to cover incidentals and personal costs.

Personal Care Reintegration Units (PCRU): Bellwoods, Etobicoke Services for Seniors, LOFT Community Services, Reconnect Community Health Services, The Neighbourhood Group and Woodgreen Community Services

Clinical Care Reintegration Units (CCRU): Hillcrest Reactivation Centre, Pine Villa, St. Hilda’s Short Stay Programs and The Rekai Centre Transitional Care Unit

Caregiver ReCharge

The focus for these programs is to provide caregiver relief and improve their capacity to transition their loved one home and continue to provide care for the client while promoting their own wellbeing.  These specialized respite services that include in-home respite (day/night), away from home overnight respite, and/or supervised programming in a group setting during the day (i.e. Adult Day Programs) have no fee (except for some incidentals) and are time limited. 

In-Home Respite – West Toronto Services for Seniors, West Neighbourhood House, Storefront Humber, The Neighbourhood Group and Bellwoods

Adult Day Program – Reconnect Community Health Services and Providence Healthcare

Overnight Respite Stays Out of the Home – Bellwoods, Etobicoke Services for Seniors, Reconnect Community Health Services and Providence Healthcare

 

To apply for any of the programs, please download the application here.

Once completed, the referral is to be sent to Centralized Referral Management (CRM) via e-mail: crm.team@one-mail.on.ca or fax: (647) 345-8999, for all the RCM Programs.  The CRM Team members will confirm eligibility and the client will be matched to a health service provider (of the selected program) by their unique needs and availability, with consideration given to geography where possible.

The Health Service Provider Team members will then work with the caregiver and/or the clients’ families on a plan for service provision.

 

For contact information:

Please contact CRM at 416-859-4376 or at crm.team@one-mail.on.ca for further information on the general programs and the referral process.

Hours are 8:30 am to 4:30 pm Monday to Friday.