At the CISSS de la Montérégie-Ouest, users with a loss of autonomy who are recovering from an acute care episode are assessed by the assessment-intervention-referral program (AIRP) to determine their needs once they leave the hospital, in anticipation of a move to a new living environment.
With beds located in a private seniors’ residence (PSR), this program is for users in stable condition who are recovering from an acute care episode but who are not prepared to return home. Care and services such as rehabilitation are provided to allow for some initial recovery; this is followed by an assessment of the person’s capacities and a referral to a new living environment.
The AIRP houses users temporarily until they can be assessed and referred to an appropriate living environment. The AIRP team is made up of a social worker, a physical therapy technician (PTT), and an occupational therapist. The target average length of stay is 30 to 60 days.
Note that there is no doctor associated with the program. As such, any user admitted to the AIRP must be medically fit to return to the community. As needed, any medical follow-up (e.g., medication adjustments) will be provided by the user’s family doctor.
- Assess the user’s level of autonomy and identify their needs in order to refer them to an appropriate living environment;
- Intervene to increase the user’s functional autonomy. Targeted interventions take place over a short period of time to help the person integrate into and remain in the planned living environment;
- Refer the user to a living environment that corresponds to their needs, based on the results of assessments and interventions done during their time in the AIRP.
- The user will be transitioned to the new living environment with support from front-line services.
This program is available with a prescription from a doctor or a healthcare professional.
Applications for admission to the AIRP can come from hospital workers, home care workers, and family medicine groups (FMGs). They must be sent by the Direction des soins infirmiers et de l’enseignement universitaire en soins infirmiers (DSIEU) to the CLSC de Valleyfield’s access desk. The consent form and usual related documents must be attached to the application.
The assessment-intervention-referral program (AIRP) is available at one private seniors’ residence on the territory of the CISSS de la Montérégie-Ouest:
- Château Romanoffe residence