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Getting seniors safely back home

PSS Team Vancouver

Members of the first Personalized Support & Stabilization (PSS) team in Vancouver.

Did you know that 10 days of bed rest ages the cardiovascular and skeletal systems in elderly people by 10 years? And, that one-third of hospitalizations result in a new disability from which half of older adults don’t recover? 

To address these startling realities and provide a better quality of life for the frail elderly when they leave our hospitals, Providence Health Care (PHC) and Vancouver Coastal Health (VCH), in partnership with Three Bridges Community Health Centre, launched the first Personalized Support & Stabilization (PSS) team at St. Paul’s Hospital earlier this week. 

Plans are in place to expand these teams across the North Shore, Richmond and Vancouver over the next year. 

Up to 8 weeks of support to increase self-reliance and optimal functionality for frail elderly ​

PSS is a new community team of interdisciplinary professionals working together to support people to safely transition, early on, from hospital settings back to their homes in the community. ​

PSS will provide “reablement” care (short-term care at home to aid recovery after discharge from hospital) to help clients increase independence. Reablement is a care approach that supports individuals to regain/maintain functionality, self-reliance and resume the activities that make up their daily lives. It aims to get clients active and back to enjoying the activities they love as soon as possible.

People are referred by acute care and provided with up to eight weeks of individualized care, uniquely designed to help clients achieve their goals, independence and confidence. Individualized care planning, in partnership with the client, will ensure a holistic and patient-centred approach to care. 

Personalized Support & Stabilization Team: In a Nutshell

  • ​Provides intensive wrap around care for up to eight weeks;

  • Gives access to a rapid response team available seven days a week with extended hours and an ability to monitor clients remotely;

  • Connects community with acute partners (i.e. geriatricians, hospitalists, etc.) early in the transition process to facilitate earlier discharges and get people back home faster so their time in hospital is shorter;

  • Collaborates with primary care professionals (i.e. GP/NPs) to ensure clients remain connected to the care they need once clients transition back to their primary care provider and community care team; 

  • Provides team based care to ensure coordination of care, effective intra-team communication and optimal patient centered care; 

  • Ensures all staff on the team are working to their full scope of practice and provides one ‘Most Responsible Clinician’ to simplify access and ensure clients know who to contact when they need help or more intensive care; 

  • Implements standardized processes and protocol driven care so there is consistency across VCH and PHC sites; and

  • Encompasses a holistic approach to getting clients back out into the world around them.

​Eligible patients must meet the following criteria:

• Are medically complex frail adults 

• Can be safely cared for at home

• Are identified as a high risk of readmission

• Don’t require 24 hour professional  care

• Have potential for functional improvement

• Wish to actively engage and participate 

• Are able to manage their condition

How to access Personalized Support & Stabilization services

Eligible patients identified in acute services are discussed at team care rounds with a PSS team member, initiating the screening and consultations required prior to acceptance. 

More about PSS teams

PSS teams are integrated across acute and community care. They include a number of health care providers including physicians, nurse practitioners, registered nurses, occupational therapists, physiotherapists, social workers, rehab assistants and community care assistants working together to support the client and their family. 

The development of the PSS teams is a partnership between the medicine and home health programs. PSS teams are part of a comprehensive strategy to transform our health system by bringing together and coordinating health care providers, services and programs that make it easier for people to access care, receive follow-up and connect to other services they need. 


If you have questions about the PSS team, please contact Yasaman August, Operations Director, Transition Services, VCH (604) 730-7668.

SOURCE: Getting seniors safely back home ( )
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