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Short-Term Transitional Care Models – Centralized Referral Management

The Short-Term Transitional Care Models (STTCM) pilot project was launched in Fall of 2017 by the Toronto Central LHIN and funded by the Ministry of Health and Long-Term Care to support the transition of patients from hospital to the community who are ALC or who are at high risk of becoming ALC without additional resources and supports. The initiatives are needs based, time limited and with no additional fee for the programs.

There are two categories of STTCM programs initiated in Toronto Central LHIN:

Reintegration Care Units (RCU)

The Reintegration Care Units (RCUs) provides patients with a short-term safe and supportive place to go post-hospital discharge. RCUs focus on client goals and needs for re-activation and engagement, while also allowing time to optimize, plan and prepare for their next community transition (e.g., home, new community housing, more supportive housing, other supportive environments etc.). Clients need to have a discharge destination to work towards at time of referral.

RCU Providers are: Bellwoods (Community Connect); LOFT (White Squirrel Way and Pine Villa), SPRINT Senior Care (Pine Villa), Reconnect Community Health Services (Doug Saunders and 2 sites), Rekai Centres (Rekai Centres Transitional Care Unit), The Neighbourhood Group (various independent units) and UHN (Hillcrest Reactivation Centre and St. Hilda’s Transitional Care Program). There is also a provider for French speaking patients with Centres D’Accueil Héritage.

Caregiver ReCharge Services (CRS)

The Caregiver ReCharge Services (CRS or ReCharge) provides short-term caregiver relief to improve the caregivers’ capacity to help transition family or friends home. This program provides services for clients in the community, while promoting the well-being of caregivers. CRS programs include short-term In-Home Respite (up to 30 hrs/month x 3 months) and short-term Adult Day Program spots. Neither program has a cost for the patient/carer.

The ReCharge Providers are: Bellwoods (Community Connect) and St. Clair O’Connor Community Centre.

 

Stepping Stones

The Stepping Stone Project (TSSP) at LOFT’s John Gibson House, was launched in 2008 with the goal to help address the challenges of transitioning seniors with history of mental health illness back to the community, who were medically ready for discharge, but no longer had an appropriate or safe discharge destination due to need for affordable and supportive housing.

 

 

 

Please see the Toronto Central LHIN Information Sheet – you can share with families – link to pdf

To apply for any of these programs, please download the application forms below: 

  • (New) Nov. 2019 Application for The Reintegration Care Units link to pdf
  • (New) Nov. 2019 Application for Caregiver ReCharge Services link to pdf
  • (New) Nov. 2019 Application for the Stepping Stones Project link to pdf
    • All applications can be completed via e-mail or fax 

Once completed, the referral is to be sent to Centralized Referral Management (CRM) via e-mail: crm.team@one-mail.on.ca or fax: (365) 300-5758 (This is not long distance #), for all the STTCM Programs. The CRM Team members will confirm eligibility and the client will be matched to a health service provider (of the selected program) based on 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 (647) 326-1424 or e-mail 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.