Sinai Health to Home
Sinai Health to Home is a goal-focused program designed to help people safely return home after a hospital stay. Patients get short-term care managed by a team of health-care providers from Sinai Health and Circle of Care, our integrated home and community care partner.
What we do
Your care team creates a needs-based plan before you leave the hospital and updates it as your goals change at home. Your hospital and home care teams work together to monitor your care during the program to prevent readmission and provide a seamless care experience.
Your care begins within 24 hours of discharge. You will receive daily nursing visits for the first seven days to ensure a smooth transition. Services are organized into different areas based on your needs: Restorative, Complex or Social.
Services may include:
- Personal support for daily activities, such as bathing and dressing
- Nursing care for health monitoring, medications and wound care
- Physiotherapy and occupational therapy to support mobility and independence
- Dietitian support for nutrition concerns and specialized diets
- Homemaking services, including dusting, mopping, vacuuming and laundry
- Social work to help with coping, planning and accessing supports
- Speech-language pathology for communication or swallowing needs, if required
- Help with equipment, home safety and transportation, and connection to longer-term community programs
Patients stay in the program until they are ready to move on, usually about eight weeks after leaving the hospital. Some patients may finish earlier if their needs are met. Others may need more support in the community after that. Your care team will discuss appropriate referrals for your ongoing needs before you leave the program.
Who is eligible
The Sinai Health to Home program is available to:
- Sinai Health inpatients who are clinically stable but have a prolonged hospital stay or are at risk of prolonged stays
- People with a known discharge location after leaving the hospital, such as a personal residence or shelter
- People living in our service area who need at least one professional home care service, such as nursing or therapy, after leaving the hospital
- Patients expected to manage on their own or with support from other home and community care services after the program ends
Eligibility is guided by the Sinai Health to Home coordinator, your hospital care team and Circle of Care. Your hospital care team will refer you to the program while you are admitted at Mount Sinai Hospital, Hennick Bridgepoint Hospital or the Reactivation Care Centre.
If you are eligible, someone from Sinai Health will contact you or your caregiver to ask if you want to take part.
Note: You cannot sign up for the program on your own. The hospital care team will assess and recommend the program before discharge, if appropriate.
If you are already using Ontario Health atHome services, they will stop during your time in Sinai Health to Home and will resume afterward. If you need to move to another hospital while in the program, your Sinai Health to Home support will end and the new hospital will take over.
What to expect
Before you leave the hospital, a team member will meet with you and your caregivers to explain the program and create a plan for when you return home. You can expect:
- A discharge plan that indicates services for the first 72 hours. Your ongoing care plan will be discussed with you after you return home
- Daily nursing visits for the first seven days, with regular check-ins afterward to ensure you get the proper support
- A Circle of Care program coordinator as your main contact for questions and scheduling
- Adjustments to your plan as your needs change, and help connecting you to longer-term supports when you are ready to leave the program
Make sure to keep your care team informed about any new symptoms or concerns so they can work with you to develop a response plan. Involving your family or caregivers to help with your care and planning may be helpful during your first days at home.
How to prepare
To ensure a smooth transition, please be ready with the following:
- Current contact information for you, your caregivers and your primary health-care providers
- An updated list of your medications and the contact details of your pharmacy
- Any special needs, equipment or home safety concerns
- Information about new symptoms, changes in your health or urgent health questions
- A person who can assist in discussion and planning
- A willingness to help create your own care plan and to let the team know if your needs or schedule change
To learn more about the program, speak with your hospital care team while you are admitted.