“Transitions can be incredibly difficult for patients living with neurocognitive disorders,” says Melissa Laroche, Director of Patient Care Service for Geriatric Psychiatry and Long-Term Care, The Royal. “We have seen how the supported transfers can reduce distress, improve continuity and help patients feel supported from the moment they left one organization to the moment they arrived at the next.” 

As the number of transfers has increased, so has the importance of supporting patients throughout the transition process. Kelly Macgregor and Christine Cook, Behaviour Support Nurses at QCH, work closely with The Royal's psychiatry team to support patients through complex transitions. Through ongoing communication and shared expertise, both teams help ensure patients receive individualized support through the transfer process. Guided by BSO transitional care principles, the approach recognizes each patient’s behaviours, routines, preferences and lived experiences. 

QCH strives to support transfers of patients at risk of physically responsive behaviours by having a Behaviour Support Nurse accompany them during transport to The Royal. The presence of a care provider during transport helps reduce anxiety, provide reassurance, and support continuity of care during what can otherwise be an overwhelming transition. 

Upon arrival at The Royal, the Behaviour Support Nurse completes a handover with the receiving nursing team. Other members of the interprofessional team, including geriatric psychiatrists, nurses, and allied health professionals, participate in the handover as available, supporting a collaborative and comprehensive transition of care. This real-time discussion helps develop a shared understanding of the patient’s cognitive, behavioural and emotional needs, enabling staff to individualize care immediately upon admission. The process has strengthened communication and collaboration between teams at The Royal and QCH, supporting greater continuity of care throughout the transition. 

For Dr. Monica Parmer, a physician at The Royal and QCH, the impact of this partnership is clear. 

“As a physician who is privileged to work at both institutions, I see the profound impact of this partnership on the care of older persons living with neurocognitive disorders. I’m proud to work alongside such collaborative teams at The Royal and QCH, whose commitment to patients, families and each other defines excellent, patient-centred care. Our partnership makes a real difference in the lives of older adults and their families.” 

What makes this collaboration especially meaningful is the intentional focus on keeping patients and families at the centre of every decision. The approach is strengthening continuity of care, reducing distress during transitions, and improving outcomes not only at the individual level, but across the health care system as well. 

Laroche recalls one transfer that reinforced the impact of this collaborative approach. 

“As I was walking away, I heard staff saying how amazing it was to have acute care staff come to The Royal with the patients and how much it decreases distress for patients entering a new environment.” 

For the teams involved, moments like this are a reminder that innovation in health care is not always about technology or large-scale change. Sometimes it is about collaboration, communication, and supporting patients through vulnerable transitions. 

This collaboration highlights the value of strong partnerships between acute care and specialized mental health services. By working together to support patients through complex transitions, teams at QCH and The Royal are helping create a more seamless and compassionate care experience.  

​At its core, this work demonstrates how interdisciplinary collaboration and person-centred care can help make complex transitions safer, more seamless, and less distressing for patients and families.