After a stay in a hospital or rehabilitation environment, returning home can be complex and difficult, particularly for those requiring a specific treatment plan and/or nutritional follow-up.

Continuum of care is key to providing a smooth return home for users and ensuring they can continue to live at home. A peer committee composed of nutritionists from various backgrounds (hospital, rehabilitation centre, CLSC, UCDG) worked to develop a simple and accessible tool to support nutritionists in preparing users for their return home.

The professionals met, identified users’ primary needs and developed a tool shared via the Smartsheet platform that allows nutritionists at the CIUSSS du Centre-Sud-de-l’île-de-Montréal to interact in a controlled environment. Facilitating access to several tools and procedures allows nutritionists to better guide and inform users before they leave. This optimizes the conditions for a safe return home, even before the CLSC nutritionist providing home care takes over.

The tool is intended to be collaborative and scalable. CIUSSS nutritionists use their varied expertise to improve the tool by adding documents aligned with best practices. While originally designed for nutritionists at our CIUSSS, the shared tool could eventually be rolled out across Quebec, allowing nutritionists in different regions to improve the continuum of nutritional care and simplify the process of returning home by coordinating the knowledge and information shared with users.

Project submitted by the team of nutritionists from
CIUSSS Centre-Sud-de-l’Île-de-Montréal, headed by Pascale Fournier