Overview/Aim
· Referrals to the BSOT team from the ED aim to reduce the number of avoidable ED visits and readmissions to hospital for older adults who present with responsive behaviours such as wandering and physically responsive behaviours.
Implementation
· Medically stable patients with responsive behaviours who are ready for discharge from the ED are identified by the ED staff and referred to the BSOT team for follow-up in the community within three working days.
· Referrals are sent directly to the BSOT team via fax or email (GEM/SW can assist with this).
· Where the situation is more urgent, a referral to the Crisis Outreach Service for Seniors (COSS) will receive a response within 24 hours of discharge/7 days a week. Referrals to the BSOT team and the COSS team can be activated by calling the Toronto Seniors Helpline (416-217-2077) a single access point for both services.
· Once a referral is received, a BSOT Nurse Practitioner (NP) will contact the client/caregiver to provide a “Rapid In-Home Behaviour Assessment” within 3 working days.
· The BSOT NP works closely with the Home and Community Care Support Services Toronto Central Community Care Coordinator to provide comprehensive assessment and follow-up, including caregiver education and support. Patients who live within the Toronto Central region are eligible for this in-home behavioral assessment/case management program (Islington Avenue to Warden Avenue and the Lake north to Eglinton Avenue/401).