Better community partnerships enhance the patient experience for Scarborough seniors

Scarborough’s getting older and wiser. With an expected growth of 46 per cent by 2028 among Scarborough residents over age 65, care for our community, in our community, is more important now than ever before.

The Scarborough Emergency Department/Long-Term Care Transitions Working Group hosted a recent conference at Scarborough Health Network (SHN), gathering the best minds in our community to share ideas and proven concepts for addressing the health needs of this population.

Formed to improve the health experience of LTC and retirement home residents, their families, and care providers in Scarborough, the working group is made up of community and health system partners, including the family member of an LTC resident, and co-chaired by SHN’s Michele James, Vice President, People and Transformation; Ivan Ip, Executive Director, McNicoll Centre, Yee Hong Centre for Geriatric Care; and Jeffrey Gardner, Director of Clinical Programs, Home and Community Care for the Central East Local Health Integration Network (Central East LHIN).

Making care seamless

Bringing together more than 100 health experts from SHN, LTC homes, retirement homes, the Central East LHIN, and community service providers from across Scarborough, the conference challenged participants to explore:

  • Providing a seamless experience for patients transitioning between hospitals, LTC centres and retirement homes by strengthening relationships between institutions;
  • Helping people who are living in LTC and retirement homes to avoid ED visits;  and
  • Giving people who are living in LTC and retirement homes safe and timely medical care at home.

In addition, the Ontario Telemedicine Network (OTN), Revera Living, Toronto Paramedics, Yee Hong Centre for Geriatric Care, and Niagara Health Services shared worthwhile insights and key learnings from their organizations.

“Each of us came to the table with common goals: comprehensive communication and better collaboration between patients, health professionals, and community partners,” said Shohreh Mahdavi, a manager within SHN’s Medicine program.

“We shared best practices and explored innovative ideas for improvement. We want the transition between LTC and retirement homes and the hospital to be seamless.”

Hands-on breakout sessions encouraged participants to identify improvement opportunities by using Lean methodology to map and examine patient journeys from LTC/retirement homes to the hospital and back again.

At the conference, Shohreh discussed how SHN’s Medicine program is witnessing positive results from a pilot project with Fieldstone Commons Care Community and the Central East LHIN’s Nurse Practitioners Supporting Teams Averting Transfers (NPSTAT) program.

“The LHIN encourages relationships between partners, in building an integrated health system. NPSTAT encourages the development of interprofessional relationships between LTC homes and the hospital,” said Shannon Poyntz, Nurse Practitioner with NPSTAT.

Working together with NPSTAT, the hospital and LTC home are working to develop better communication and collaboration between care providers. A shining example of this work is the new standardized documentation tool used to assist with the transfer of information between the hospital and Fieldstone Commons.

This new tool is the result of a survey of 22 LTC homes in Scarborough and all three SHN hospitals. Of those who responded to the survey, 100 per cent of LTC home directors of care, physicians, and nurse practitioners, and 90 per cent of hospital physicians agreed standardized documentation would be useful. 


The standardized documentation tool has resulted in increased patient health information being shared at the outset, enabling care providers to better understand a patient’s condition upon arrival to the hospital; treat patients more quickly and efficiently; and communicate to patients, family members, and the LTC home more clearly about a patient’s health condition and follow-up care plan.

They were right. The new tool has resulted in clarity for residents and families about what’s happening with their health and follow-up care, and has reduced hospital length-of-stay and unnecessary readmissions for patients.

“The project has made a significant impact in our hospital transfers. The issue of gaps in information between the hospitals and LTC homes has required improvement for years,” said Rodolfo Ramon, Interim Director of Care, Fieldstone Commons.

“Designing the pilot project with SHN was a great learning experience; it helped us put ourselves in their shoes and vice-versa. The pilot project ensured that both parties had more than enough information to provide the best care possible for LTC residents. I would strongly encourage other LTC homes to do the same.”

According to Shannon, next steps include building initiatives to help LTC homes access hospital staff in order to facilitate transitions between sites. In addition, the standardized documentation tool will be rolled out broadly to support care transitions between all three SHN hospitals and Scarborough’s LTC and retirement homes.

Yee Hong Centre for Geriatric Care was one of the presenters who kicked off the conference by describing how for many residents, avoiding transfer to the ED and being cared for by the LTC home is much preferred.

They set the stage by featuring the voices of residents, families, and nursing staff to ground conference participants in their experiences. They also showed a video of some of their residents and families speaking in their own language (Chinese), supported by subtitles – a wonderful reflection of Scarborough’s diversity.

The presentation illustrated how sometimes, a trip to the ED is necessary, but in many cases moving an older person significantly impacts the person’s health and wellbeing. This is called relocation stress: every time a senior is moved, the body experiences stress.

By improving the exchange of information between the ED and LTC home, both parties can better determine if and when a resident should be brought into the hospital, what kind of treatment is required, and the appropriate follow-up care.

“I’m very proud of what we accomplished through this conference,” said Ivan.

“We are all here to work together to improve the experience of residents, patients, families, and all the health care providers. We want everyone to feel confident in the health care system.”

A healthier tomorrow starts in Scarborough

For SHN, this work supports every aspect of the organization’s new strategic plan.

“Shaping a healthier future is core to the work that we do at SHN. But we can’t do it alone,” said Michele.

“Thanks to the cooperation, dedication, and, most of all, passion, of all of the participants of the Scarborough ED/LTC Transitions conference and working group, together, we can confidently say that a healthier tomorrow starts in Scarborough!”

Though the conference is over, the collaborative work to enhance outcomes for LTC and retirement residents continues, with the Scarborough ED/LTC Transitions Working Group looking to spread this type of cross-sector partnership to other local issues. Stay tuned for updates on this exciting work!


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