Mary Gariffe, patient of the Providence Care Transitions Home program, poses with her Occupational Therapist Lexi Bulak and Social Worker Leland Herrington.
By: Jonna Semple-Kloke, Communications Officer, Providence Care
When 72-year-old Mary Gariffe left Providence Care's Providence Transitional Care Centre and returned home, it came with equal parts excitement and worry.
“I was excited to get home but I quite liked it there [Providence Transitional Care Centre]. Everybody worked towards the common goal of getting you home and I enjoyed the programming too."
Once home, Mary's programming, care and services didn't stop. As a patient of Providence Care's Transitions Home program, Mary has allied health therapists from the hospital care for her, but now in her own home.
“Mary gets the full spectrum of the therapies offered through the Transitions Home program," says Occupational Therapist Lexi Bulak. “So that's social work, occupational therapy, physiotherapy and recreational therapy; these are the focus of our team."
The Transitions Home program is available to patients and clients discharged from Providence Transitional Care Centre and Providence Care Hospital. Since Transitions Home became fully funded in November 2023, the program has led to a 45 per cent reduction in emergency room revisits and a 42 per cent decrease in all-cause readmissions within 30 days of hospital discharge.
“We're providing transitionary support inside the patient's home to add safety, independence, mobility and confidence," explains Clinical Program Coordinating Supervisor for the Transitions Home program, Sheryl Gibson. “We use a team approach across all four disciplines, beginning in the hospital and carrying on into the community, which is very beneficial. “Our team aims to see patients in hospital whenever possible, before they go home, and the team members are always communicating with one another," adds Sheryl.
Mary is a patient of Transitions Home following three surgeries and a stay at Providence Transitional Care Centre for a torn quadricep. In physiotherapy sessions she works on using her walker to get around her two-storey home and neighbourhood. Occupational therapy helps Mary with daily tasks of living, like feeding her cat and three dogs, while social work sessions support the emotional journey of her injury and her changing family dynamic. Recreational therapy is what Mary says she really enjoys. It encourages her to explore lost or forgotten hobbies, while also getting her involved with community activities and events.
“I'm really happy to see everybody and I always know who I'm opening my door to. I have goals to start sleeping on the second floor again and recreation therapy has helped sign me up for the Seniors Association to get involved in activities. You know, eventually the program will end for me and it's sad. I look forward to the company and it's been so helpful," explains Mary.
In addition to reducing hospital readmissions and visits to the emergency department, Sheryl says Providence Care's Transitions Home program is also reducing hospital stays by bridging the gap between levels of care from hospital to home.
“The program has saved over 1,000 patient days and prevented more than 500 days of patients waiting in hospital for alternate levels of care. We have helped more than 300 patients transition from acute to post-acute care more quickly."
Care plans within Transitions Home are individualized and based on need, so not everyone in the program receives all four therapies like Mary. Length of stay in the program is also dependent on the patient's requirements and is set to maximize independence and safety, helping people live at home well.
“My sessions with the therapists always complement each other," explains Mary. “There's a steady flow and there doesn't seem to be a division or separation between everybody or what I'm doing. Everything works together. I always feel like the therapists are talking to each other," she adds.
“Our therapists call each other multiple times per day and they do joint visits sometimes," explains Sheryl. “Social work and occupational therapy (OT) might go together because OT is going to be tackling something challenging so social work will be there at the same time to offer support. They bounce ideas off one another and figure out things together. They're a team that knows one another well and work well together which is really resulting in success for our patients."
As Mary works to fully transition to living on her own again, she says she's focused on her mobility, balance and overall comfort and confidence in her own home. She hopes to continue building strength so she can walk unassisted and go up and down her stairs without anxiety.
"Every day is better than the one before and every day I get less afraid. I was terrified going upstairs, but I'm not afraid anymore. I'm building confidence and talking myself into trying new things, while at the same time, balancing listening to my gut about how much I can take on at once."
Embodying a commitment to comprehensive, continuous care, Providence Care's Transitions Home program is supporting recovery and well-being at every step, bridging the gap in care. Patients like Mary are experiencing a seamless journey from hospital to home and are set up for success to live well. The Transitions Home program and the staff who work on the frontlines, traveling across the southeast region, are transforming transitioning from hospital to home into a smooth, supportive pathway for patients and their families, all while reducing stress on hospitals.