Sinai Health to Home: Supporting recovery at every step

Sinai Health to Home supports patients at Mount Sinai Hospital, Hennick Bridgepoint Hospital and the Reactivation Care Centre who no longer require hospital care but need a safe plan and coordinated support to continue their recovery at home.

Launched in November 2024, the program connects hospital to home through Circle of Care, Sinai Health’s community health-care partner. Hospital care teams work with patients and care partners to recommend the necessary supports, and Circle of Care organizes the plan and arranges community providers.

"This program is built on communication and collaboration," says Rebecca Ramsden, Senior Clinical Program Director, Specialized Medicine, Complex Care and Transitions at Hennick Bridgepoint. “We know care transitions are where the experience can drop off and information can get lost. Our goal is to provide smooth, coordinated care where all steps in the process address our patients' needs.”

Personalized plans for every patient

Each Sinai Health to Home patient receives a personalized, short-term, goal-based plan that may include nursing, physiotherapy and other health-care services. It can also help with equipment, transportation and longer-term community programs.

"Leaving the hospital is anxiety-provoking for a lot of people," says Sabrina Gaon, Director of Social Work, Complex Transitions and Community Reintegration at Sinai Health. "Patients feel more comfortable knowing they have a lot of support. But the care plan adapts — services can scale up or down as people gain strength and confidence."

Care that continues beyond the hospital

Planning begins before discharge with a care plan that outlines services for the first few days at home. Care begins on the day of discharge or within one day of going home. During the first week, a nurse checks in daily and the care team adjusts the plan as needs change. On day one, Circle of Care sets up supports and works with the patient, caregivers and the Sinai Health to Home coordinator — a nurse based at Circle of Care — to prevent readmissions and support recovery.

“What sets our program apart from traditional home care is that patients have a direct line to the Sinai Health to Home program,” Sabrina adds. “The program is compact, scalable and consistent; it’s not a constantly changing cast of people. If issues arise, patients know they can connect with the program, so there’s no gap in care.”

A unique partnership

Sinai Health to Home and Circle of Care connects our hospitals, home care and community supports through a longstanding relationship. Early results show strong satisfaction, with a majority of patients reporting better access to services and inclusion in care decisions.

“What’s remarkable is how it builds on the strong foundation between Circle of Care and Sinai Health,” says Adeela Kausar, Circle of Care’s Director of Client Services. “That spirit of collaboration has allowed us to form truly interprofessional teams and design a model focused on one thing above all: making the transition home as seamless and supportive as possible for patients.”

To learn more about the program, visit the Sinai Health to Home information page.