Complex Continuing Care

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Patient Services

Our programs include:

• Geriatric Assessment
• Functional Enhancement
• Medically Complex

Geriatric Assessment

This is a comprehensive interdisciplinary geriatric assessment program that includes an observation period to evaluate the results of treatment. The goal of this program is the development of a personal discharge plan that includes education to support family members and links to the community. The average length of stay for this program is 14-30 days.

Eligibility

• In need of nursing and/or medical management services which cannot be provided in another environment.
• Medically stable.
• Need for comprehensive multidisciplinary assessment and treatment.
• Older adults who are frail and ill and have complex medical, functional, or psychological problems.
• Specific conditions include:

  	Multiple pathologies
  	Polypharmacy Recent deterioration or unpredictable response to illness
  	High risk for institutionalization
  	Multiple visits to emergency
  	Symptom complexes such as incontinence, confusion, and falls

ADMISSION FORMS Fax to: (519) 894-8324
INQUIRIES Telephone: (519) 749-4300, ext. 7272 (Resource Nurse)

Admission Application: Demographic Information (Microsoft Word)
admission application: Assessment unit referral (Microsoft Word)

Functional Enhancement

This low intensity, functionally focused reactivation program is aimed at returning patients to home or to a lower level of care.

Eligibility

• In need of nursing and/or medical management services which cannot be provided in another environment.
• Medically stable.
• Need for comprehensive multidisciplinary assessment and treatment.
• Demonstrates the potential to attain functional goals that will positively influence level of independence and quality of life.
• Committed to returning to the community, utilizing family and other supports, or to a lower level of care.
• Medical and rehabilitation needs can be met within unit.
• High level of dependency (two person transfer) with potential for improvement.
• Requires and can tolerate 15 minutes of active therapy daily.
• Minimum age 18.

ADMISSION FORMS Fax to: (519) 894-8325
INQUIRIES Telephone: (519) 749-4300, ext. 7194

Admission Application: Demographic Information (Microsoft Word)
Admission Application: Rehabilitation, restoration & functional enhancement (Microsoft Word)

Medically Complex Unit

This is a resource for patients with chronic and complex clinical conditions requiring a range of multidisciplinary diagnostic and therapeutic services and technologies. The goal of the program is to discharge patients to the home or to a lower level of care.

Eligibility

• In need of nursing and/or medical management services which cannot be provided in another environment.
• Medically stable.
• Need for comprehensive multidisciplinary assessment and treatment.
• Clinical interventions requiring frequent, ongoing professional assessment/intervention; treatment/support.
• A pattern of frequent, intercurrent, or progressive illness requiring increased professional services/intervention.
• Patients for whom maintaining a state of equilibrium is possible only because of concentrated professional care and/or technical support.

ADMISSION FORMS Fax to: (519) 894-8349
INQUIRIES Telephone (519) 749-4300, ext 7176

Admission Application: Demographic Information (Microsoft Word)
Admission Application: Complex Continuing Care (Microsoft Word)