Community Outreach Team at West Bedford Transitional Health fills critical gaps in care

It’s not easy being the new kids on the block in a busy and complex healthcare system. But now that transitional health has entered the landscape as a new model of care in Nova Scotia, a unique community outreach team is learning how to navigate its evolving role, helping each client it serves.

West Bedford Transitional Health opened to clients in December 2024 (a smaller location opened in the summer) with the goal of getting patients home safely following a hospital stay. The beautiful new facility gives people time to regain strength, confidence and independence, away from an acute care setting. 

For some patients, going home comes with a daunting array of challenges. That's where Lynda Culley and her team step in to provide a vital safety net.

"We’re kind of the glue that holds it all together," explains Culley, manager of the Community Transitions Outreach Team for West Bedford.““Our team helps patients plan their discharge and make short-term follow-up visits and arrange required programs and services, at both Nova Scotia Health and within the community.”

Culley's team of care coordinators, occupational and physical therapists, rehabilitation assistants and a behaviour resource consultant, work closely with patients and their families prior to and after they leave West Bedford Transitional Health. They conduct home visits, set up necessary services, equipment and technology, and quickly respond to any issues that arise. Soon the team will expand to include a social worker, which with further enhance the team’s holistic approach to treating the whole person.

"We have the ability to send a team member out to a home the same day if we hear a patient is facing a concerning barrier," says Culley. "Our team is small and nimble, so we can pivot quickly to address a client's changing needs."

That agility is crucial, as everyone’s living situation is so different. For example, when the outreach team discovered an elderly patient's apartment was unsafe, the team sprang into action, buying some groceries and temporarily relocating the patient to ensure their safety and wellbeing. 

"That's the kind of work we do - looking beyond just the medical needs to understand the full picture of how a patient is living and what they'll need to be successful at home," Culley explains. "Our team is empowered to think creatively and do whatever it takes to support our clients, some of whom are vulnerable."

Christy Hunt, the team’s behaviour resource consultant, plays a vital role in supporting patients transitioning from West Bedford Transitional Health back to their homes. "I support people living with cognitive impairments, their families, and care partners," says Hunt. She collaborates with healthcare and community providers to develop care plans and continues to follow up once patients are settled at home.

Hunt's extensive network includes Continuing Care, home care agencies, VON, Red Cross, community occupational and physiotherapists, The Alzheimer Society, Caregivers Nova Scotia, Community Health Teams and food programs like Meals on Wheels. This collaboration ensures that each patient's unique needs are met during their transition home.

Involving patients' families early in the transition process is crucial. With the patient's consent, the Community Outreach Team collaborates with the patient and their identified family member to discuss a home visit, view the home environment and address any equipment needs that could delay discharge. 

For patients requiring ongoing medical care or supports after leaving the transitional health facility, the team provides support for up to 16 weeks. The team shares important information with family primary care providers about any medical issues they observe. 

With an innovative approach and commitment to holistic care, the Community Outreach Team at West Bedford Transitional Health ensures that every patient receives the comprehensive support they need to thrive at home.

Photo: West Bedford Transitional Health's community outreach team (L to R): Christy Hunt,Behaviour Resource Consultant; Lynda Culley, Manager; Tom Stanley, Physiotherapist; Hailey Armitage, Rehab Assistant; Lori Kennedy, Rehab Assistant; and Fiona Brann, Occupational Therapist. Missing from photo: Mark Budden