Partnership with UHN provides seamless transitions with clients at the centre
In 2022, VHA entered its third and biggest year yet of partnership with the University Health Network (UHN)’s Integrated Care (IC) program.
The Integrated Care program was launched in 2019 to provide an evidence-based model of care aimed at improving the client, caregiver and care provider experience. In collaboration with UHN, VHA’s Lead Homecare Agency and Service Provider role enables clients to have a seamless care experience transitioning from hospital patients to home. Once clients are in stable condition at the hospital, they can be sent home with additional support from VHA care providers, freeing up space in the hospital while allowing clients to be where they are most comfortable.
Jennifer Chen, visiting nurse at VHA, cares for UHN IC program clients in their homes across the Greater Toronto Area. She witnesses the positive client outcomes seen as a result of this program on a daily basis.
“We are the eyes and ears of physicians and surgeons once our clients return home from hospital,” says Jennifer. “Most clients need instruction and assurance so they can properly rest and relax for an effective recovery.”
The UHN IC Program provides care to both medical and surgical patients. The current medical population is General Internal Medicine clients including those with Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and COVID+ care needs. The team also provides care to thoracic, vascular, cardiovascular, orthopedic, and most recently transplant surgical clients.
In-home services can include nursing care, personal support, occupational therapy, physical therapy, speech language pathology, social work and dietetics, or a combination of several. These services are customized to meet the unique needs for each client. Throughout the program, clients also have access to a 24/7 program phone line which includes on-call nursing support after hours and weekends.
Prior to joining VHA, Jennifer worked for over 9 years in a rehabilitation hospital where she helped patients gain back their strength and independence after a serious medical illness or injury. Becoming a nurse working with the UHN IC program felt like a natural fit.
“Given the nature of many of these complicated surgeries and conditions, many people I see are struggling with pain and they are anxious about their symptoms. Clients are always very relieved to have the opportunity to ask questions. Our team also reports anything that is concerning to the IC team at UHN, where they can involve the client’s physician or surgeon if needed for further instruction,” notes Jennifer.
The integration of care between UHN and VHA means that the entire care team works together and puts clients at the centre to make sure a seamless, high-quality experience is delivered during each and every transition from hospital to home.