Your point of access for the Short-Term Transitional Care Model and Stepping Stones Programs
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 initiative was needs based, time limited and with no additional fee for patients transitioning from hospital to community. The Toronto Central LHIN, in partnership with the Ministry of Health and Long-Term Care (MOHLTC), is continuing to invest in testing the STTCMs, and specifically the Centralized Referral Management program (CRM) and Reintegration Care Unit (RCU) program for the 2020-2021 Fiscal Year.
See below for further details on both of these programs.
What are 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 post-RCU transition destination or plan 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 congregate setting and other independent unit sites)
- Rekai Centres (Rekai Centres Transitional Care Unit)
- The Neighbourhood Group (independent units in a permanent housing building)
- UHN (Hillcrest Reactivation Centre and St. Hilda’s Transitional Care Program)
- For French speaking patients: Centres D’Accueil Héritage.
What is the Stepping Stones Project
The Stepping Stones Project (TSSP) at LOFT’s John Gibson House, was launched in 2008 with the goal to help address the challenges of transitioning seniors (55+) 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.
Following the launch of the RCU programs in 2017, our hospital partners identified the need for a rapid, consistent, effective process for referral management and CRM was launched in February 2018 to address that need. Once referrers complete one of our 2 referrals (see below) and forward them to firstname.lastname@example.org or fax them to or fax (365) 300-5758 (This is not long distance #), the CRM Team will respond within 1 to 3 business hours, with confirmation of client eligibility for these programs and reach out to you with one of the following:
- confirmation that your patient has been matched to program and what the next steps will be
- that we require further information to match
- that your patient has been placed on a waitlist
- that we have exhausted all resources in the RCU or Stepping Stones programs and your patient cannot be matched, at which time we will connect you to our Community Resource Navigator (CRN).
The Community Resource Navigator (CRN) in turn will reach out for a consult to:
- aid you with decisions around where we transition clients other than RCU
- how we transition them to community and
- how we may support them once they are there with additional resources.
The CRN aims to remove barriers to discharge and increase flow and capacity by providing guidance, education and information around: housing; community-based resources; next step through guided problem solving; and education and support in the implementation of best practices in the transition of clients from hospital to other destinations, as per Health Quality Ontario transition standards.
Please see the Toronto Central LHIN Information Sheet which includes steps for referring, tips on which patient may be a good fit and some information on our RCUs – link to pdf
If you are unsure that your patient is a candidate for an RCU or the Stepping Stones Project, or that you may benefit from consultation with our Community Resource Navigator, please do not hesitate to email or call our CRM Team (CRM: (416) 447-1224 and CRN: (416) 447-1173) for consultation.
Monday to Friday 8:30 am to 4:30 pm