Description of Services:
An enhanced transitional care program designed to support patients with dementia, cognitive impairment, or responsive behaviours who require additional behavioural and caregiver support to return home safely from hospital
Building on the traditional Southlake@home model, PLUS provides individualized care focused on recovery, safety, behavioural management, caregiver education, and maintaining independence at home * patients have access to comprehensive services, including nursing, physiotherapy, occupational therapy, personal support, and other interdisciplinary supports based on their assessed needs
Through partnerships with LOFT and CHATS, the program offers specialized behavioural assessments, individualized management strategies, caregiver coaching and counselling, community navigation, and wheelchair-accessible transportation when required * these additional supports help families manage responsive behaviours, reduce caregiver stress, and build confidence in caring for their loved ones at home
A Coordinator works closely with patients, families, hospital teams, and community partners to ensure a seamless transition home and coordinated delivery of services
The program provides support for up to 16 weeks, with connections to ongoing community services as needed.
Goal is to prevent unnecessary hospital admissions, facilitate earlier and safer discharges, reduce avoidable emergency department visits, and empower caregivers to support their loved ones safely and confidently at home
Wheelchair Accessible