Photo caption: Patients in the Tillsonburg District Memorial Hospital Transitional Care Unit engage in group restorative care activity.
By: April Mullen, Integrated CNE & VP, Clinical Services; Angela Stuyt, Integrated Manager, Clinical Services; Brooke McPherson, Integrated Coordinator, Clinical Services
Faced with mounting pressures such as increased Emergency Department (ED) volumes and high inpatient occupancy rates, ranging from 135-150%, Tillsonburg District Memorial Hospital (TDMH) found itself at a critical tipping point. These pressures led to backlogs of admitted patients in the ED, prolonged average lengths of stay (ALOS), and increased wait times within the ED. TDMH was operating over capacity with an average of 12 unfunded operational beds open daily, peaking up to 16 beds. The hospital was in an access and flow ‘code gridlock’ often.
TDMH is a small rural community hospital, with 34 acute medical surgical beds, 10 Complex Continued Care beds, and 6 Level Two Advanced Intensive Coronary Care beds.
After discussion with the regional office on the access and flow challenges, TDMH successfully received funding support to open a Transitional Care Unit (TCU) within the hospital. On April 1, 2025, the 12 bed TCU unit opened for Alternate Level of Care- Long Term Care (ALC-LTC) patients waiting for placement, where discharge home was not thought to be a safe option. The TCU was to be a short-term solution to allow patients to receive the ‘right level of care’ while they were awaiting their discharge destination. The TDMH Foundation generously supported capital equipment needs.
The model allows ALC-LTC patients within the hospital to be cared for in a dedicated unit designed to meet their care needs. The unit staffing model includes Nursing, Personal Support Workers (PSW), Physical and Recreational Therapy, and medical oversight. TCU patients reside in rooms set up to feel at home, with access to common spaces for socialization.
The TCU model includes a Physiotherapist assessment to develop a patient treatment plan aligning with discharge goals. A Physiotherapist Assistant/Occupational Therapist Assistant provides individual or group exercise classes, and a Recreational Therapist provides recreational interventions to enhance socialization, engagement and emotional well-being five days a week. An Occupational Therapist is available as needed to complete functional assessments related to activities of daily living.
A TCU Standards of Care and Documentation policy was created to support senior-friendly nursing, PSW, and rehabilitation practices on the unit, outlining evidence-based standards of care and practices. The TCU team fully embraced best practices in ALC, Delirium Quality Standards and Senior Friendly Care. Initiatives such as congregate dining promote social engagement and help establish a structured daily routine, both essential for seniors’ well-being. Standardized screening and risk assessments are completed on the unit, with particular attention to daily monitoring for fall risk, cognitive changes (using the Confusion Assessment Method), and skin integrity (using the Braden Scale). Patients benefit from a variety of therapeutic programs tailored to the needs of older adults, including horticultural therapy, art and music, as well as physiotherapy programs like Movement Matters and Move On, all aimed at maintaining mobility, independence, and cognitive function.
The TDMH Team received feedback from a family member highlighting the success of the initiative: “The care my mother received was excellent! Everyone was so caring, respectful, and treated my mom with dignity. Before she arrived at TDMH, she was assessed and deemed a candidate for LTC. After being at TCU, she improved to such a degree that she was able to move up to the level of moving into a retirement residence instead. TDMH should be proud of their new unit and the amazing staff who give such great care to all the patients.”
The TCU was co-designed with front line team members and patient advisors to inform processes and meet the principles of patient and family centered care. Setting the model of care to be restorative in nature meeting all ALC and Older Adult leading practices through team education has been pivotal to the unit’s success. Due to the high level of restorative care provided in the TCU, patients have gained more independence and discharge destinations have been altered from LTC to retirement home or home. Due to the high number of TCU discharges, the acute inpatient access and flow pressures have successfully reduced inpatient occupancy rates. Overall, the success in opening this TCU demonstrates the hospital setting can be adapted to meet the needs of ALC-LTC patients, achieving high quality care outcomes at lower care costs than acute care.