Bringing it home: Community partnership helps patients transition seamlessly from hospital with SHN@Home

When a patient is in the hospital, surrounded by a team of nurses, doctors, therapists and more, they feel secure. They are confident and comfortable knowing they have their support system to provide them with the best care. But when the time comes for a patient to go home, they may experience feelings of unease or fear as they transition to being away from the hospital. This is where SHN@Home comes in.

Scarborough Health Network (SHN) has partnered with Bayshore HealthCare, Integrated Care Solutions to create SHN@Home – a seamless discharge care plan for patients who require continued restorative care when they are transitioning home from the hospital. The SHN@Home team is comprised of care coordinators, nurses, personal support workers, occupational therapists, physiotherapists, speech-language pathologists, social workers and dietitians – all dedicated to working closely with the patient, their family and their hospital team to make sure their care plan meets their needs at home.

We are thrilled to be working together with Scarborough Health Network on this program, which frees up valuable hospital space for more critically ill patients, all while helping patients meet their goals,” notes Anita Fitches, Director, Integrated Care Solutions at Bayshore HealthCare. “Bayshore‘s contribution to the program is multifaceted and helps ensure a smooth transition home while ensuring that patients have all of the necessary supports in place.”

The program is comprehensive and has been designed with the patient in mind. Through a series of check-ins with the SHN@Home care team, patients can be confident their journey to optimize their rehab goals is our priority when staying in hospital is no longer required. As patients needs change, their care team will work with them to adapt to what best suits their needs.

SHN@Home enables patients with diverse care needs to continue to work towards their restorative goals in their home environment. The individualized care plans are tailored to meet the unique needs of each patient and connects them with the appropriate services and support. As part of the seamless transition from hospital to home, Bayshore participates in discharge planning calls with the SHN team, to ensure that patients and their families are aware of what to expect.

In a patient’s first week home, they will receive a call from their SHN@Home team to make sure they’ve arrived home safely, as well as receive an in-person visit from a member of their team. They will receive daily check-ins every day of their first week home, and then will work with their team to determine how often the patient requires continued check-ins based on their needs, comfort level and support requirements.

“This partnership came from a joint desire and passion to ensure a continuity of care for our patients as they return to the community,” shares Nancy Veloso, Director, Medicine, Transitional Care and Senior’s Health. “The collaboration between Bayshore and SHN has allowed us to continue to provide the exceptional care for our patients that they receive in hospital, even when they’re not within our walls anymore. We’re extremely thankful for Bayshore and for all of the members of the SHN@Home team for their commitment to ongoing quality care for their patients.”

Through the collaborative partnership of SHN and Bayshore HealthCare, SHN@Home connects patients with the services that best suit their needs – from community supports, rehabilitation or even helping a patient find a primary care physician if they don’t already have one.

Helping patients receive the therapy they require sooner rather than later after discharge helps them get back to a level of functioning faster and allows them to return to their independent lifestyle.

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