The Centralized Referral Management (CRM) piloted in Toronto is designed to support inpatients and their caregivers in the transition from hospitals to at-home convalescence, as well as reducing Alternate Level of Care (ALC) days in hospital. This initiative is needs-based and time limited, and is in partnership with 13 different Health Service Providers (HSP) in the community.
This research project is a collaboration of investigators in Ontario, Quebec, and Alberta to support stronger primary care for older adults living with frailty. Effective assessment of frailty will allow older adults to remain in their homes and communities. Primary care clinicians will use the Assessment Urgency Algorithm tool, which uses a scale of one to six, to determine frailty level. This ensures a client is connected to the right type of service, at the right time.
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An effective referral management system helping hospital and community referrers access the range of transitional care and respite supports available within Toronto. By moving intake online, we can deliver better coordinated care and more efficient transitions.