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The Winnipeg Regional Health Authority is creating a new short-term, intensive home care service to support elderly patients once they have been released from hospital.

The move is designed to reduce the number of elderly patients who are placed in personal care homes after being released from hospital because they lack proper support at home.

The enhanced service, set to begin this fall, will provide elderly patients with up to 90 days of intensive home care while they complete their rehabilitation, says Gina Trinidad, Chief Operating Officer of Long Term Care and Deer Lodge Centre.

"We're hoping to reduce the number of seniors being discharged to a personal care home by approximately half, by providing them intensive support to continue their convalescence at home. We know that seniors recover better in their own homes," says Trinidad.

Experiences in other jurisdictions, such as Ontario and Alberta, have shown that this type of service promotes better and rapid recovery of the individual and often delays or eliminates personal care home (PCH) placement, as most clients can continue to stay home with regular home care supports.

"In Winnipeg, we have the highest PCH bed count per capita, because the continuum of care for the elderly here is not as robust as it is in other jurisdictions," says Trinidad.

Approximately 1,200 people in hospital are paneled for admittance to a PCH per year. Fifty per cent of those people should be able to return to their own home, with support from this enhanced home care service, says Trinidad. Diverting these patients from personal care homes will create improved capacity for people who need the 24-hour care in a PCH, she adds.

"Once we're up and running, we can handle close to 250 clients at a time," says Trinidad, adding that the patients are mostly elderly, although there might be younger people with a chronic illness who would otherwise be moving from hospital to a PCH.

Supports include personal care, nursing and medical care and supportive and restorative therapy. The service will be staffed by health-care aides, home-support workers, nurse practitioners linked to a primary care physician, occupational therapists, physical therapists, rehabilitation aides and other disciplines.

"Sometimes people just need some time to recover and rehabilitate," says Trinidad. "Perhaps they might have had a fall. They might have had surgery. They may just need some time to convalesce. But hospital environments often don't serve the elderly well because they are busy places. So if a patient isn't making strides quickly while in hospital, the panelling process will be started for the patient to move to a PCH."

Clients targeted for the enhanced home service are individuals who are able to return home with the enhanced supports safely in their own home and in their own communities to recover from a hospital stay and who also have family supports who are willing to continue in the caregiving role with home care support.

"This is a necessary step in beginning to enhance the continuum of services for the elderly outside of the hospital environment," says Trinidad, adding that once the intensive home care service is complete, most clients will continue to use regular home care services.

Once the new service is launched in late fall, the Region will keep track of key performance indicators, such as the number of clients served and their length of stay on the program.

"Many people start by going to an emergency room, get admitted to hospital, and then get moved on to a PCH. We want to divert that stream, and get them back home again," says Trinidad.

Susie Strachan is a communications specialist with the Winnipeg Regional Health Authority.