Complex Continuing Care

The Helen Aird Carswell Complex Continuing Care (CCC) Unit is committed to patient-centered, senior-friendly care, with an emphasis on compassion and improving quality of life. We have multiple specialties to deliver care to people with complex, non-urgent medical needs.  

We support people in recovering their strength, mobility and maximizing their independence to improve their overall health and well-being. Our interprofessional team include doctors, nurses, transition navigators, respiratory therapists, a behaviour therapist, personal care workers, physiotherapists, occupational therapists, speech language pathologists, dietitians, pharmacists and interfaith chaplains. Together, our interprofessional care team works with patients and their families to develop an individualized treatment plan that meets their needs.

Complex Continuing Care Services

Our goal is to optimize the quality of life for individuals who have chronic complex conditions.  

Long-Term Ventilation Program  

This program provides 24 beds and a stimulating environment that enhances quality of life for medically stable ventilator-dependent patients. An interdisciplinary team of care professionals work collaboratively to support the care of individuals admitted to this program who require mechanical ventilation for all or part of a 24-hour period. 

Eligibility Criteria

The program is targeted to patients who require chronic ventilation and respiratory care services all or most of the time in a 24-hour day and who have a valid OHIP number. Admissions are assessed on a case-by-case basis.  

Patient eligibility requirements include: 

• Be medically stable for past 30 days 
• No constant monitoring requirements 
• No inotropes in the past 30 days 
• No significant changes in medication in the past 30 days 
• No major cardiac or respiratory events in the past 30 days 
• Supplemental oxygen less than 40% on or off the ventilator 
• No hemodialysis unless patient can attend outpatient clinic on their own 
• No nasogastric (NG) tube (patient either takes food orally or switched to G/J/PEG tube) 
• Appropriate ventilator settings 
• All patients should be fully ventilated at night utilizing set respiratory rate rather than pressure support 
• Suctioning cannot be more frequent than every two to three hours 
• Suggest lung hygiene routine (e.g. cough assist, breath staking) for patients on trach mask for patients who have an ineffective/weak cough 

Referrals

Referrals to the program are made through Resource Matching and Referrals’ (RM&R) Centralized Long-Term Ventilation Waitlist (LTVHub) for Intensive Care Units (ICUs) within the Greater Toronto Area. For referrals outside this area, please fill out the appropriate referral form and send to @email. (Program Manager). 

Short-Term Inpatient Rehabilitation  

This program provides short-term, multidisciplinary inpatient rehabilitation for patients recovering from elective surgeries and other orthopaedic conditions. Patients participate in a 12-week program with the focus on improving function and mobility to help patients reintegrate into the community or transition to home. The care team provides education to support health promotion and fall prevention to patients and families to reduce the risk of re-injury. Once discharged, patients can benefit from a continuum of care with community resources. 

Eligibility Criteria

Admissions are based on MGH’s inpatient wards and on a case-by-case basis. 

Key Partnerships

• Home at Last Program 
• MGH2home
• Meals on Wheels 
• Toronto Grace Remote Care Monitoring
• Woodgreen Seniors Services
• Various private care organizations such as: Home Instead, Seniors by Seniors by Spectrum Health, Bayshore Home Health, ADA Extended Home Care

Memory Care Unit 

This 12-bed unit supports patients with advanced dementia. Patients on the Memory Care Unit (MCU) and families will be supported in developing personal plans to transition back into the community, home or long-term care. 

Our philosophy of care includes optimizing quality of life through a strengths-based, collaborative, interprofessional and holistic model of care that incorporates Gentle Persuasive Approaches (GPA) to dementia care.

The team works to identify underlying causes of responsive behaviours while implementing and continually evaluating the effectiveness of pharmacological and non-pharmacological strategies. The team develops a Behaviour Care Plan which is transferrable to the patient’s identified discharge destination. Furthermore, the team supports the patient’s transition by ensuring that behavioural support information is communicated and shared amongst all community care partners. 

Eligibility Criteria

Admissions are based on MGH’s inpatient wards and on a case-by-case basis.

Key Partnerships

• LOFT Community Services – The Path Home  
• WoodGreen Community Services – Adult Day Program, Caregiver Support 
• Baycrest Centre – Virtual Behavioural Medicine  
• Long-term care homes – Transitions 
• Alzheimer Society of Toronto 
• Behavioural Supports Ontario-Assessment Tools, Behavioural Support for Seniors Program (BSOT), Psychogeriatric Resource Consultant (PRC), Committees

Palliative Care

This program aims to optimize quality of life and care for patients with life-limiting illnesses. Our interdisciplinary team focuses on pain and symptom management and offers expert and compassionate end-of-life care to patients and families. Our goal is to offer pain and symptom management to your loved one to increase their comfort, relieve their suffering and improve their quality of life. 

Eligibility Criteria

Admissions are based on MGH’s inpatient wards and on a case-by-case basis

Key Partnerships

• Home and Community Care Support Services – Toronto Central

Atrium at Kew Beach Unit – Transitional Care 

The Atrium at Kew Beach Unit is a comprehensive transitional care centre that is part of MGH. It hosts patients who are alternate level of care (ALC) or waiting for long-term care (LTC) placement or convalescent care. MGH collaborates with community partners at the site to ensure an interdisciplinary team can support patients’ needs and quality of life. The centre is an initiative of East Toronto Health Partners, the Ontario Health Team that MGH is part of.

Eligibility Criteria

Admissions are based on MGH’s inpatient wards and occasional case-by-case basis.

Key Partnerships

• LOFT Community Services – Behavioural Supports  
• WoodGreen Community Services
• Home and Community Care Support Services – Toronto Central 
• VHA Home HealthCare

RESOURCES

• Hospital Chronic Care Co-Payment
• A Guide to the Substitute Decisions Act
• Advance Care Planning