Skip to main content

Services of the Behavioural Support for Seniors Program

As lead for the project, Baycrest is working together with many community partners, and bringing together all parts of the system involved in caring for seniors with behavioural challenges. The goal of the Behavioural Support for Seniors Program is to collaboratively implement Behavioural Supports Action Plan within the Toronto Central catchment area.

Program goals

  • Improve quality of life, and outcomes, for older adults (and their families) who have challenging behaviours.
  • Increase specialized behavioural support capacity in long-term care homes.
  • Improve co-ordination and reduce fragmentation of the community behavioural support system to ensure more equitable and timely access to services.
  • Increase specialized community capacity/outreach to support individuals to stay in their existing environment, reduce or prevent unmanageable behaviours.
  • Improve transitions across the continuum.
  • Increase workforce skills and training for providers across the continuum.
  • Improve caregiver education and support.
  • Prevent unnecessary and avoidable emergency room visits and potential hospitalization for clients with challenging and unmanageable behaviours through access to an enhanced model of care.
  • Reduce hospital alternative level of care days.
The Behavioural Supports Coordinating Office is responsible for the Centralized Intake of BSO Outreach Teams (Community, LTC and Acute Care), Geriatric Addictions Specialist, and Caregiver Specialist referrals in the Toronto Central region.

To access our referral form and detailed program information, please visit our website.

BSO Outreach Teams (Community/LTC/Hospital/Transitional Care)
Behavioural Support Outreach Team (BSOT) in all Sectors: Community, LTC and Acute Care

In LTC and Community, an interdisciplinary team of clinicians including Clinician Leaders, Nurse Practitioners, Behaviour Support Specialists, Registered Nurses and Personal Support Works (PSWs) across AST, Baycrest, Home and Community Care Support Services Toronto Central, and Woodgreen.

Acute care teams consist of LOFT BSTR (Psychogeriatric Case Managers and PSWs) and UHN BSS (Behaviour Support Specialists and PSWs)
These outreach-based services engage across all sectors in the short-term (average lengths of service is 8-10 weeks) and focuses on assessment and management of responsive behaviour(s). The team(s) will also support patient transitions between all sectors and will foster collaboration with various resources and care partners. 

Service is delivered virtually and in-person as needed.

Behaviour Support Outreach Team (BSOT) Emergency Department (ED) Program

One of our Advanced Practice Nurses (Nurse Practitioner/Clinical Nurse Specialist) will contact the patient /family/SDM within 3-5 business days to complete an in-depth “rapid in-home behavioural assessment” (with short-term follow-up as indicated) for discharged ED patients who are referred by one of the 7 ED’s in the Toronto Central Region. These assessments include an in-home medication review. If there is no primary care or if the patient is poorly connected to primary care, the NP will assume the role of PCP on a short-term basis. BSOT operates in collaboration with the Crisis Outreach Services for Seniors (COSS) teams who will do home visits sooner than 3 business days if needed.

Specialized BSO Services

Geriatric Addictions Specialist

Support for older adults with Substance Use Disorders (with or without dementia) who reside in long-term care, or who are transitioning to long-term care. Substance use disorders include: addiction to alcohol, opiates, cannabis, nicotine, benzodiazepines and other drugs. The Geriatric Addiction Specialist will support care teams and caregivers with a transition plan to support cessation or harm reduction to ensure safe transition to LTC and safe care within the LTCH environment. This includes consulting on cases where the home is considering declining an application due to addiction or substance use.

For more information on Substance Use and Behaviour Support click here

Caregiver Specialist

The program is based at Alzheimer Society of Toronto, funded under BSSP Toronto Central Region. It supports caregivers of people with dementia living in the community, through transitions, and in LTC.

Transitional Behavioural Support Unit (TBSU)

Located at Baycrest, this 23-bed, specialized transitional unit provides support for individuals whose behaviours have become unmanageable in their current setting. The client’s behaviours are stabilized until they are able to be returned to their home. Eligibility is determined by the Home and Community Care Support Services – Toronto Central. The average length of stay is four months.

For healthcare professionals: TBSU Fact Sheet

Crisis Mobile Service Enhancement

An expanded mobile crisis team, provided throughout Toronto Central region by Woodgreen Community Services, to ensure older adults receive the support they need.

To access the Crisis Outreach Service for Seniors (COSS), please call the Toronto Seniors Helpline (TSH) at 416 217 2077.


Education and Training Consortium

A wide range of integrated and coordinated education and training to enhance knowledge and expertise of caregivers, primary care practitioners, long term care staff, community health service providers and acute care personnel. The consortium is comprised of the Centres for Learning, Research & InnovationThe Regional Geriatric ProgramThe Alzheimer Society of Toronto, and Baycrest.

See a list of helpful links