Residents of LOFT's Back to Home - Bradford House program, Denise and Brian with some of the LOFT Team
Health System News recently spoke with Debra Walko, Vice President, Client Care & Experience and Heather McDonald, CEO, at LOFT Community Services, about their successful Back to Home Program and how it's benefitting individuals with unique health care needs. By providing tailored supports within the community, such as affordable supportive housing, LOFT's programs are helping people transition from hospital to a more appropriate setting, allowing them to live safely and thrive within the community.
Why is LOFT's Back to Home Model needed and who does it serve?
Across Ontario, a growing number of people with complex needs end up being designated as alternate level of care (ALC) and remain in hospital even when they no longer need to since the supports they require aren't available. This includes a lack of affordable supportive housing that can meet their unique needs. For example, a recent Canadian Medical Association Journal (CMAJ) article also highlights the growing numbers of people experiencing homelessness who rely on extended hospital-based care, and why hospitals are building housing to address the lack of alternative solutions. And last year alone, there was a 56 per cent increase in people designated ALC in Toronto; 25 per cent of them are seniors with cognitive, behavioural, addictions and mental health challenges.
This is where LOFT's Back to Home Model can make a real impact because it focuses on meeting the various physical, health care, and mental health needs of individuals facing complex mental health challenges, addiction, dementia, and responsive behaviours who don't have access to appropriate housing and support services. LOFT's programs help these individuals to live safely and thrive within the community.
LOFT has 17 ALC-specifically designed supportive housing sites. Working together with integrated partnerships, this successful model has four components:
- Health and well-being (e.g., specialized personal care, 24/7 nursing, primary care, intensive psychogeriatric case management for mental health and addictions, etc.)
- Social drivers of health (e.g., stable affordable housing, meaningful social connections, tailored food services, etc.)
- Behaviour support (e.g., individualized behavioural support plan, knowledge exchange with client's circle of care, etc.)
- Life enrichment (e.g., life skills, meaning making, cognitive stimulation, etc.)
What has the impact been?
Last year, 487 people who were designated ALC transitioned from hospital to LOFT's supportive housing, meaningfully impacting their lives. LOFT's client satisfaction rate is 90 per cent.
Brian is one of LOFT's valued clients who has struggled with major illness and substance use. Over two challenging years, Brian had constantly transitioned between hospital beds and living arrangements, including group homes and shelters. He had accumulated over 120 ALC days. The prospect of leaving the hospital became a source of anxiety, but he finally moved to Bradford House in 2018.
“With the support of Bradford House, I have been able to stabilize my physical and mental health. It has been a while since I have seen the inside of a hospital room. I really don't know where I would be without the truly amazing support I have received and continue to receive during my journey."
The model has had an impact on more than just the people it serves. It helps reduce costs for the system and eases pressure on hospitals. A total cost savings of $2,225,453 was estimated from housing 26 hospitalized individuals for 12 months, and, for one partnership, the ALC rate went from 25 to 16 per cent. Hospitalizations and emergency room visits also decreased by over 85 per cent during the first year, improving overall population health. After people transition from hospitals to these support services, they rarely, if ever return to the hospital.
“LOFT’s transitional space has been an absolute game-changer for Trillium Health Partners and patients who have complex physical, cognitive, social, and/or mental health needs. Until we worked with LOFT, these folks were declined from every housing or care setting and languished in hospital.”
– Stephanie Joyce, SVP, Patient Care Services & Health System Integration, Trillium Health Partners
Advancing health equity is another major benefit since marginalized individuals can access dignified housing with tailored supports that consider intersectionality. The care providers also enjoy greater well-being through integrated, interdisciplinary teams with a strengths-based approach, more innovation and autonomy, and by creating joy and meaning in their work!What has made this model successful?
The key to the model's success is a commitment to a shared vision by LOFT and its hospital partners – from the frontlines to senior leadership – that's founded in person-centred tailored services, integrated partnerships and collaboration, and enablers of excellence. This sets the tone for the teams, especially on the frontline, who are supporting these transitions.
The trust that's built at every level enables flexibility and innovation needed to creatively solve challenges that arise and also facilitates a seamless transition for patients/clients. This trust is built on transparency. For example, when LOFT is unsure about whether a transition will work for a particular client – we're upfront about the support we're able to provide. At times, this has meant working with our hospital partner and jointly deciding on a trial run to ensure the client's needs are met and that they're happy in their new environment. Each patient is assessed individually, and hospitals trust LOFT to care for the patient well.
On our end, we ensure that staff receive specialized training to navigate behavioural issues, the intersection with physical health, and mental health and addictions issues. Our hospital partners are a resource for community partners, providing essential services and support like with falls prevention, and infection prevention and control (IPAC).
Which hospitals have you collaborated with and how did these partnerships develop?
We've partnered with both acute and regional mental health centres including the Centre for Addiction and Mental Health, Humber River Hospital, Michael Garron Hospital, Sunnybrook Health Sciences Centre, Trillium Health Partners, University Health Network, and Waypoint Centre for Mental Health Care.
What's needed to spread and scale this model? Who can play a role – and do you see one for hospitals?
Additional investment is needed to make available housing affordable, and built according to current standards, especially around accessibility, to pay for meals and other core services. Basically, it's about removing any barriers to running these programs. That said, our partnerships with hospitals involve careful planning around funding pre-implementation to ensure the program is set up for success.
Beyond investment, a critical catalyst for scaling this model is realizing what's possible, rather than focusing on traditional approaches. With limited resources and the demands of a growing and aging population, health care providers need to find more creative ways to deliver care that's tailored around the needs of patients/clients, sustainable, and prioritizes equity.
For example, LOFT offers respite services to patients who arrive at hospital emergency departments (EDs) and don't need to be admitted. One hospital reached out to us about a client with dementia who ended up in their ED. Pine Villa took him in to provide his caregiver respite. All parties had their needs met in the best way possible.
Hospital clinicians who check on their patients post-transition are uplifted by seeing their former patients now thriving outside of the hospital. Many are brought to tears. What's vitally important to all partners is uniting around a common goal – to transform the lives of those we serve to offer them a better quality of life.