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June 02, 2021 Linh Tran* survived the Vietnam War by escaping to Canada, fled an abusive marriage and raised four children as a single mother. The traumas she endured impacted her mental health but they didn’t explain the memory issues, poor judgement and disinhibited behaviour she started to exhibit in her late 50s. Her family tried their best to care for her at home but it was extremely challenging. She became aggressive, delusional and paranoid.

At age 61, Linh was diagnosed with frontotemporal dementia, an uncommon, degenerative brain disorder that often begins between ages 40 and 65, and is characterized by dramatic changes in personality and behaviour. When she was admitted to an acute care hospital for help, she required 24-hour care and supervision, and a security guard had to be posted in front of her room to keep her from trying to leave.

That’s when Linh was referred to the Behavioural Neurology Unit at Baycrest for its expertise in assessing and treating complex neurological diseases and associated behaviours. 

It took many months on this short-term, inpatient unit to clarify her diagnosis, and find the right medications and interventions to stabilize Linh’s behaviours to the point that she could finally be accepted to a behavioural support unit in a long-term care facility.

Understandably, Linh’s children were worried about moving their mother to an unfamiliar environment when she was doing so well at Baycrest. “I was pretty nervous about how the transition would go because Baycrest was like a home to my mother, but the team was very reassuring and supportive,” says Linh’s 28-year-old daughter, Annie.* “They explained that the staff at the long-term care home would be fully aware of how to care for her, and that no one had ever had to come back after being discharged.”

Staff at Baycrest and Cummer Lodge where Linh now lives say the transition was a success due to a new integrative discharge support process involving Baycrest’s Virtual Behavioural Medicine (VBM) Program and Behavioural Supports Services.
 
The new process begins with a virtual meeting between Baycrest staff, local Behaviour Support clinicians and staff from the long-term care home to discuss in detail the patient’s unique history, care plan, triggers for behavioural issues, strategies to manage behavioural issues, daily routines, abilities, preferences, etc. and provides an opportunity for the new staff to ask questions of Baycrest staff.

In addition, the patient and the care team at the long-term care home have access to virtual, follow-up visits with Behavioural Neurologist Dr. Morris Freedman or other physician specialists through the VBM Program – a collaboration between the Sam and Ida Ross Memory Clinic at Baycrest and the Toronto Central Behavioural Support for Seniors Program (TC-BSSP), which assesses and treats people with challenging behaviours caused by dementia and related cognitive disorders.

“That virtual, rapid access to a specialist is very helpful for the staff in the long-term care home,” says Adrienne Lee, Clinical Navigator in the Behaviour Supports Coordinating Office at Baycrest. She explains that some long-term care homes are hesitant to accept new residents with challenging behaviours or to accept them back after they’ve been on an inpatient Behavioural Neurology Unit. This new integrative process with post-discharge supports was created to help alleviate their concerns.

Theresa Jin, the charge nurse on the Behavioural Support Unit at Cummer Lodge, says her team appreciated this new transition process and found it very helpful.

“It wasn’t easy for this resident to settle into a new environment with new people but because Baycrest gave us a detailed care plan and we were aware of her behaviours, we could apply a number of strategies to calm her and she’s doing so well,” Jin explains. “It took a couple of weeks for her to become familiar with the staff and her surroundings, but now she’s eating well, following instructions, communicating with staff and even helping other residents.”

“The opportunity to have a virtual, follow-up visit with Baycrest and the potential for support if needed is very helpful to our team,” says Dr. Elizabeth Johnston, Medical Director at Cummer Lodge. “In this case, the resident settled in quite well and no additional support was required, but it was nice for our team to get kudos from the Baycrest staff when they heard how well the resident was doing.”

Dr. Johnston has used the VBM Program for virtual consults with other residents who would otherwise have been unable to attend a meeting in person. “It’s beneficial for our residents and for our staff.”
 
* names have been changed to protect their privacy
 
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