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Acute Care Transitions Leadership: SE Health Collaborating and Co-designing to Ensure Safe Transition from Hospital to Home

Written by Melissa Wallace from, continue reading below. Source:

When Masooma Baqueri’s 77-year-old husband, Mir, woke up in the middle of the night in June and suddenly fell on his way to the washroom, she was dismayed to learn he had fractured several ribs.

Weighing on Masooma’s mind was when Mir had knee replacement surgery years ago and she sought help for him, making calls and waiting at length for service providers to help her husband recover.

But this time was different. In hospital, her husband was referred to MackenzieHelps, an integrated care program that helps patients over the age of 65 to transition from hospital to home, arranging all necessary health-care services, transportation and caregiver supports.

“Everything is co-ordinated for you and I didn’t have to call to get everything done,” said Masooma. “It was a complete program where everyone knew the whole situation and the nurses, physiotherapists and caregivers were very empathetic, friendly and really cared for him to get well soon.”

MackenzieHelps began as a 16-week pilot program in November 2019 and has since evolved into a collaborative effort between Mackenzie Health, SE Health, Community and Home Assistance to Seniors (CHATS) and LOFT Community Services as part of the Western York Region Ontario Health Team serving King, Vaughan and Richmond Hill.

“This innovative and integrated model is reinventing how we deliver authentic patient and family-centred care and inspiring our commitment to home care modernization,” said Nancy Lefebre, chief operating officer and senior vice-president at SE Health. “Using a dedicated, ‘one team,’ interdisciplinary and flexible care approach, SE Health staff in all roles are bringing hope and happiness, while facilitating a safe and seamless transition from hospital to home.”

“One of the reasons the program has worked so well is because the team has a ‘shared care plan’ that has essentially been a game changer,” said Mary-Agnes Wilson, executive vice-president, chief operating officer and chief nursing executive, Mackenzie Health, using digital tools that support the work and allow all care providers to document and have access to the same shared health records. Supporting seniors the way they want to receive care is important, she said, particularly in western York Region, where there are now more people over the age of 65 than people under the age of 15.

“In the three years that we’ve been up and running, we've successfully cared for over 500 patients through this program,” said Wilson. “On average, we've been able to reduce and save about three days’ length of stay for these patients.”

The number is “significant,” she said, as the longer patients stay in hospital, the longer it takes to recover.

Sony Singh, CHATS’ integrated care manager, said CHATS’ involvement includes designing individual care plans to ensure a patient’s successful integration back into the community. 

“CHATS has seen the benefits from our clients enrolled in the program by receiving direct support from our dedicated staff who assist with information, referrals and co-ordination to various services offered such as Meals on Wheels and referrals to a wide range of community supports,” said Singh. “Not only has the service been beneficial to the clients, but also their caregivers, where the staff provide support, information/education, and referrals for caregivers to reduce caregiver burden.”

Another aspect of the project is MackenzieHelps Plus, a 26-week program that offers assistance to help families better manage patients who may have a form of cognitive decline and might be more challenging to care for at home.

“Many individuals living with dementia can experience responsive behaviours that can be distressing to the individual and their care partners,” said Suzanne Saulnier, LOFT’s director of behavioural support services. “LOFT supports the MackenzieHelps Plus program by coaching on approaches and strategies to prevent and respond to responsive behaviours. We promote positive, trusting relationships with those we support and their families, ensuring meaningful change can occur.”

To arrange for MackenzieHelps services, patients or their loved ones can contact a patient care co-ordinator on their floor prior to leaving the hospital, who can then help make the appropriate referral.