WHAT WE SET OUT TO DO
Most of the medical care a person will receive in their lifetime will happen at a community hospital like St. Joe’s. Following their stay with us, many patients will continue to receive care from community or home-based healthcare providers. We play an important role in facilitating smooth transitions between these touchpoints. We want patients to have the right care at the right time, whether they are at St. Joe’s or at home. That’s why we are committed to working with healthcare providers to better coordinate services both inside and outside the Health Centre to create a safer and smoother care journey.
WHAT WE ACHIEVED
Connecting patients to supports outside the hospital
We recognize that the ability to lead a healthy life is often connected to your social and economic wellbeing. For patients who live with mental illness, a lack of secure housing can be a barrier to receiving care. That’s why we partnered with West Toronto Housing Help Service to help patients in our mental health programs find affordable housing or maintain their existing homes; providing wraparound supports for people that need them most.
Making paediatric care more accessible for busy parents
We’ve extended our reach into the community even further with a new partnership with the Toronto District School Board. Students from 11 elementary schools within our neighbourhood can see a specialized team of paediatricians and family physicians at our new clinic located in Parkdale Public School to address health issues that may impact a child’s academic achievement.
Preparing patients to go home
As patients prepare to leave the Health Centre, it’s important that they have the information they need to continue their recovery process and avoid any unexpected visits back to the Health Centre. Confusion about appointments, medications or the severity of symptoms can lead to problems. We partnered with Open Labs to pilot a new patient-oriented discharge process that helps patients understand exactly what to expect when they leave the hospital and who they should contact if they have any issues.
James has struggled with anxiety for as long as he can remember, but never got the treatment he needed. “I took care of my mom for many years and when you’re a caregiver, you tend to forget about yourself,” he said. Following the loss of his mother and a particularly stressful time in his life moving from Hanover to Toronto, he knew he had to get help.
“Everything was hitting me at once,” he recalls. “I was having difficulty finding a doctor and getting my medical information together – it was hard to keep up.”
With complex medical issues and limited support to navigate his care journey, James found himself in the Emergency Department more times than he can count. As part of a new initiative, James was referred by our staff to HealthLinks, a partnership between several healthcare providers and community agencies.
“For many people without regular access to medical care, the Emergency Department can become their main resource,” said Deborah Egan, HealthLinks Team Lead. “Our goal is to connect people to healthcare providers in our community to better coordinate care for patients with complex needs.” James was connected to Solmaz, a social worker at LOFT Community Services who has helped him meet his personal and medical goals and, most of all, given him back his sense of independence. “This is the first time I’ve had my own place in 50 years and it’s because Solmaz helped me out – I’m really grateful for that.”
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