Centralized Referral Management

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.

Caredove has configured services to display results in 3 main categories:

  • Prevention & Health Promotion for scores 1 & 2
  • Community Support Services for scores 3 & 4
  • Specialized Geriatric Services for scores 5 & 6
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Funded ByProject Sponsor

Toronto Central LHIN

Network Search SiteAlberta Network Waterloo Wellington Network

Refer to Bellwoods Intake Program which can match your client to 13 agencies.

Lead Agency

Bellwoods Centres for Community Living

Funded ByProject Sponsor

Toronto Central LHIN

Overview

  • Reintegration Care Units (RCU)
    These units support patient transitions from the hospital to short-term transitional care units in the community that provide a safe and supportive place to help patients increase strength, mobility and endurance to support their transition home or into an alternative care setting.
  • Caregiver ReCharge Programs
    These programs provide caregiver relief and improve their capacity to transition their loved one home and continue to provide care for the client while promoting their own wellbeing.  These services include in-home respite (day/night), away from home overnight respite, and/or supervised programming in a group setting during the day (i.e. Adult Day Programs).



  • The Process
    The Centralized Referral Management Team members will confirm eligibility and the client will be matched to a health service provider (of the selected program) by their unique needs and availability, with consideration given to geography where possible.
    The Health Service Provider Team members will then work with the caregiver and/or the clients’ families on a plan for service provision.
  • Agencies
    Bellwoods, Hillcrest Reactivation Centre, LOFT Community Services, Pine Villa Sprint, Providence Healthcare, Reconnect Community Health Services, Rekai Centre Transitional Care Unit, St. Hilda’s Towers Senior Care Unit, Storefront Humber, The Neighbourhood Group, West Neighbourhood House, West Toronto Support Services for Seniors, Woodgreen Community Services

Results

December 2018 project performance

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Join Bellwoods Centralized Referral Management System

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.

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