Restorative Care Service

Restorative Care Unit, 2 East & West,
St. Peter’s Hospital,
Hamilton Health Sciences
88 Maplewood Avenue, Hamilton, Ontario
L8M 1W9 

Number of Inpatient Hospital Beds - 44 Complex Care beds (we are not acute care, rehabilitation, convalescent care, retirement home, transitional care, or long term care)

Co-payment - Patients admitted are not required to pay a co-payment.

Patient Population - Patients with multiple medical and/or functionally complex conditions who are expected to benefit from low intensity, longer duration interventions and rehabilitation therapy, provided by an interprofessional team, with clearly articulated functional improvement goals that can be attained within an average length of stay.

Average Length of Stay - The average length of stay is 45- 60 days. The Restorative Care Program is a time-limited program designed for complex care patients who require some additional hospital care.  In collaboration with the patient and family, the goal of the interprofesssional team is to enhance the health and quality of life of the patient, and assist the patient to meet specific goals to transition back into the community.  When a patient has met their goals or reached a natural stopping point, the patient will be discharged home or to a retirement home.   

Admission Criteria

• Age 18 years of age or older (paediatric population by exception)
• Presence of significant physical/functional impairments
• Physical tolerance that permits participation in programming- two or more hours daily of therapy
• Goal to go home or to a retirement home, not to a long term care home
• Patient and Family/Substitute Decision Maker are supportive and in agreement with the transfer to the Restorative Care Unit
• The patient needs daily skilled assessment by an interprofessional team
• The patient needs two or more services not including nursing

Medical Stability

The most responsible physician is on the unit one day/week, available by phone at other times.  For other urgent issues staff call the on call physician from the monthly physician roster.

• The patient has completed the acute phase of illness
• All consults and diagnostic tests for the purpose of diagnosis or treatment of acute conditions have been completed and reported or pending test results are not anticipated to dramatically change the treatment plan
• All abnormal lab values have been acknowledged and addressed  as needed
• Acute medical issues have been resolved or reached a plateau and are not fluctuating and the patient is not requiring acute daily medical interventions by a physician
• Medically stable with some weight bearing status and patient’s pain is controlled.  Unit will manage PICC lines, IV therapy, IV antibiotics, PEG tubes and feeds, wounds and dressings, and stable tracheostomies.
• If a Restorative Care patient becomes ill and cannot be managed in Complex Care, they will be transferred to the Hamilton General Hospital, often by a call to “911”

Program Readiness  

• Clearly defined goals have been established.  Goals should be specific, measurable, achievable, realistic and timely (SMART goals)
• Treatment of other co-morbid illnesses/conditions does not interfere with patient’s ability to participate (i.e. active treatment that results in frequent absences from the unit during treatment/therapy sessions)
• Minimum of 2 hrs of therapy i.e. OT, PT, SLP etc.
• A discharge destination has been discussed and documented

Restorative Care Team - Physician, Nurse Practitioner, RN Case Manager, Social Worker, Physiotherapist, Occupational Therapist, Rehabilitation Assistants (OTA/PTAs), Speech Language Pathologist, Communicative Disorders Assistant, Registered Dietitian, Pharmacist, Registered Nurses, Registered Practical Nurses, Registered Respiratory Therapist, Business Clerk, Clinical Nurse Specialist/ Wound Care Specialist, Environmental Aides, Volunteers, and Clinical Manager.

The team works closely with the Local Health Integrated Network (LHIN).

Referral Process - A member of the Healthcare Team from a referring facility or the community will complete the application form, the “Hamilton Niagara Haldimand Brant (HNHB) LHIN Acute Care to Rehab and Complex Continuing Care (CCC) Referral. The “Letter of Understanding about Complex Care” must also be completed. Completed hospital applications are faxed to the hospital-based LHIN Office (previous CCAC), and community applications are faxed to LHIN Placement Services, fax number 905-574-2402. 

Members of the Restorative Care Team will review the referral and accept or decline the patient, and accepted patients will be added to the wait list and admitted when a bed becomes available. Depending on the length of time waiting, patients who have not demonstrated progress or patients whose condition has declined, may no longer be appropriate for a Restorative Care bed.

Hamilton Niagara Haldimand Brant (HNHB) LHIN Acute Care to Rehab and Complex Continuing Care (CCC) Referral Form