Aman* used to be a teacher back home in Ethiopia before he fled to Canada as a refugee. But now he was nearing the end of a two-month stay at VGH, slowly recovering from multiple stab wounds that paralyzed his vocal chords, injured his face, limited the use of his hands and restricted his ability to swallow so much that he initially needed a feeding tube.

“I asked him where he wanted to go, and he kept repeating that he wanted to go home,” recalls Cathy Castro, a transition services coordinator at VGH who was part of the care team planning his discharge. But home—to supported housing—was not an easy option.

At first, the team thought residential care would be an appropriate place.

“We were all concerned about his risk of aspiration,” says Linda Hollett, a social work case manager on the Pender home and community care team. “If he ate solid food, he could be at risk of choking, infection or aspiration pneumonia. And we weren’t sure if he truly understood the risk, due to the language barrier, his history of mental illness and possible cognitive impairment.”

“There was a degree of risk in sending him home, but he was in his early forties,” says Cathy. “My gut feeling was to give him time to heal and prove himself because it was what he truly wanted.”

Teamwork prevails

It took multiple case conferences between Cathy, the Pender home health team, and mental health team before they felt confident they could support Aman, and his modified diet, at home.

A pre-discharge home visit also gave them a full picture of his home life.

“He had strong culturally-appropriate support at home,” Linda says. “He didn’t have family but there were people who spoke his language and genuinely cared about him. We had to get them all involved to ensure he could go home safely.”

Within a week he was discharged, with home support workers visiting him three times a day to crush his medication, blend his food and monitor his swallowing while he ate.

An example of a larger shift

Getting a patient home under the most challenging circumstances illustrates a shift happening across Vancouver—and the numbers prove it. The teamwork between acute and community staff has resulted in a 12 per cent reduction in residential care registrations this year, and a 21 per cent decline in patients going straight to residential care from the hospital.

At home with the right supports, clients generally have their best chance to regain their strength and independence. And, returning home frees hospital and residential care beds for those who truly need those levels of care.

Linda Hollett, a social work case manager with Pender Home and Community Care, helped Aman get home.

“He’s thankful to be home”

When asked how long the community team will follow-up on Aman’s health, Linda laughs, “We could follow him forever. As case managers we are attached long-term, although the support he needs may decline over time.”

“Now he wants to take a class three afternoons a week and is gaining more independence by blending his own food,” she adds. “He’s thankful to be home in his community.”

After his follow-up appointment at the trauma clinic, Cathy says he went to say hello to the staff on the nursing unit where he recovered.

“He is a prime example that we can get people home and delay or avoid residential care if we all work together,” she says.

*Name changed