184 7.6.3 Acute Care Partnerships

Health Standards Organization^[1] National Standard for Long Term Care Services recommends high quality safe care, in the appropriate setting. Due to age and complexity, transfers to acute care may be needed based on resident wishes. This standard includes considerations for hospital transfer of LTC residents:

• Transitions in care
• Safe and sustainable repatriation
• Hospital acquired delirium and/or complications, and infectious exposure (e.g. COVID)
• Potential for admission avoidance
• Strategies to meet care in needs in LTC

Transitions in care:

• Seniors with multiple comorbidities are complex and lead to increased mortality and service use
• Transitional care  interventions support improved outcomes and coordinated/integrated service.
• Attending NP and NP programs supporting LTC are instrumental in integrated care, safe transitions and timely follow up

Acute care partnership pearls:

• Acute care has interest in avoiding ED visits and shortening length of stay
• Partnership with acute care may facilitate care pathways to: outpatient clinics and programs
• Leverage collaboration with specialties such as geriatrics and palliative care
• Enhanced communication benefits both sectors: transitional care coordinators, HCCSS, GEM nurses
• Educating acute care of LTC capabilities
• Opportunity to address a gap in services