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Care Transitions

Imagine if patients could be safely discharged to the location of their choice, with the care and services they need, without waiting, and... ALC didn't exist.

Building on our track record of performance, clinical excellence and proven technology leadership, our goal is to support people to live at home for as long as possible.

Key Features of our Care Transitions programs include:

  • Clinical Expertise and Dedicated Community Based Care Teams
  • Jointly designed and implemented pathways of care
  • 24/7 access to care aka Call in line
  • Virtual care through our IntelligentCare Platform
  • Patient-and-Family-Centered Care (Link to PFCC)
  • Quality and Audit System

Home Care support post an acute care visit

Discharge from hospital represents a big change for many patients, their families and caregivers. While in hospital, patients have 24/7 access to highly qualified staff and resources, and therefore the transition home without the immediate access to these resources can result in anxiety and fear. By creating unique programs of care, designed in collaboration with hospitals, we have been successful at providing a sense of comfort with the transition from hospital to home not only for patients and families, but also for hospital clinicians who are discharging patients to a known and trusted collaboratively designed program of care.

Our focus is on creating a simple and comfortable process for patients by providing clarity as to the services that will be delivered, ensuring proper education and reliably delivering on services when requested and as planned.

During a patient’s transition, our support begins with monitoring the patient’s continued recovery from their acute care hospitalization, and quickly transitioning to the education and support patients and families need to support self-care and independence.

Where appropriate our Care Transitions programs leverage technology to improve patient experience, patient engagement and connections with health care providers. SE Health’s IntelligentCare technology platform is cloud based, and incorporates best practices to meet Canada’s strict privacy and security guidelines. It provides enhanced access to health care services for patients in their home. IntelligentCare improves patient, family and caregiver experience while providing greater engagement between and them and their health care team.

Personalized Monitoring Plan & Remote Patient Monitoring

Standardized monitoring plans can be personalized to reflect the types and cadence of health data required to monitor recovery. These include patient biometric readings, symptom assessments, medication adherence, activity tracking, and nutrition. Monitoring can be performed remotely thanks to bluetooth connected devices and an intuitive mobile app allow patients to easily capture and review their own health data. By connecting the dots between what they do and how they feel, patients are empowered with the knowledge for self-care and to participate as active members of their care team

Reactivation

Sometimes patients need a little more time to regain the level of independence that they had prior to an admission to acute care. The option to transition from hospital to a reactivation center before discharge home can help clients safely and comfortably regain the skills, mobility, strength and confidence they need. Reactivation Centres play an important role in Alternative Level of Care prevention.
The SE Reactivation Care Model emphasizes the development of personalized plans of care with each client, with a focus on increasing independence. Reactivation Care optimizes clients’ physical, mental and psychological health, working towards:

  • Increased strength, mobility, and endurance;
  • Improved ability to complete the activities of daily living in their homes; and
  • Enhanced confidence in their ability to return safely to, and thrive in the community