A journey of compassion: West Bedford Transitional Health’s community outreach team's first year

When West Bedford Transitional Health opened its doors to patients one year ago, it marked the beginning of a bold new venture into uncharted waters. The first-of-its-kind partnership between Nova Scotia Health and Shannex set in motion a new model of care that would begin to reshape the healthcare landscape.  

For Nova Scotia Health’s community outreach team, much has changed since day one. The team started out with a shared goal: help patients leave a hospital setting and return to the place they call home and thrive. Today, a team of 15 works closely with patients, family members, and community-based organizations to make this happen.

Christy Hunt, outreach team lead and a behavioural resource coordinator at West Bedford, says the team’s growth was not just about numbers. “We’ve learned to work together and adapt to a rapidly changing system,” she said. "We've had our growing pains, as any new team does, but we've also had incredible opportunities to learn and grow together."

The team follows the Home First philosophy, challenging traditional beliefs about patient care and recognizing that many patients can recover at home with supports. "There were times when I initially thought, 'This is not going to work. How will we get this person home?' But time and again, patients proved us wrong. Sometimes, you don't know until you try," said Christy.

Patients and their loved ones are asked to fill out a satisfaction survey following their stay at West Bedford, and their comments show the team’s efforts are paying off. “My whole experience with West Bedford has been a joy,” said one patient. “My care was outstanding, and my outreach team is a dream. My physiotherapist has contacted me or visited after each doctor’s appointment.”

“The team is wonderful support for my husband as he transitioned from hospital to home,” wrote a family member. They are caring, understanding, and provide a valuable service that has made a difference in my husband's recovery.”

Christy says seeing patients reconnect with their lives at home has been the ultimate reward. "Being able to sit in their favourite recliner, cuddle their cat or dog, or reconnect with their church community - that's what makes our work so meaningful," she said.

They've also discovered that their work benefits people beyond traditional medical care. "We are providing holistic care," said Christy. “Many clients, especially older adults, look forward to our home visits, so we are filling a social void in their lives.”

Open communication has been the team’s secret weapon. "If we have a challenging situation, we reach out to each other and talk it out," Christy explained. "There's trust within our team to have honest, constructive conversations, and that has a significant impact on how we work together.

Wendy McVeigh, director of community transitions at Nova Scotia Health, says she is deeply grateful to work with such a dedicated team. “Since opening one year ago, we have proudly supported 220 people, helping them rebuild their strength, restore their confidence, and work alongside them to identify and arrange the resources needed for a successful recovery at home,” said Wendy. “It is incredibly rewarding to be making a difference in people’s lives.”

Reflecting on the past year, the outreach team has also made significant strides in networking and strengthening relationships with community partners. Caregivers NS has been a major supporter, and the team is now participating in their social prescribing pilot project, which has opened new avenues for patient care.

Within Nova Scotia Health, the team’s occupational therapists have formed valuable connections with the Acquired Brain Injury (ABI) and ABI outreach teams, as well as specialty seating services, to better support patient needs. The team continues to collaborate with organizations such as the Red Cross, Continuing Care NS, and Community Health Teams, referring patients whenever possible to ensure they receive comprehensive, well-rounded support.

As they look toward the next phase at West Bedford Transitional Health, the team remains committed to their core philosophy: home is best, and with the right support, most people can thrive in their own environment.

Photo: Members of Nova Scotia Health and Shannex teams celebrate one year of transitional care.