A new program that transitions patients out of hospital who no longer require in-hospital care* in consultation with the program coordinator, patient, patient's family, and the hospital team, a care plan is created that meets the care the patient needs at home * the team consists of care coordinators, nurses, personal support workers, occupational therapists, physiotherapists, social workers, and dietitians in partnership with Bayshore HealthCare. * the plan will be shared with everyone who will be involved in providing patient's home care * the first home visit will be scheduled before patient leaves the hospital

Within 24 hours of leaving the hospital, the patient will get a phone call from a member of the team to make sure patient has arrived home safely * the team will:

• visit patient within 24hrs of arrival home
• check in with patient for the first three (3) days
• after the first week, the patient and the team will decide on frequency of check in
• work closely with the hospital to ensure patient goals are being met after patient gets home
• keep patient's family doctor up to date on patient's progress
• use different ways to check in and care for patient through: home visit, phone calls, technology like telemonitoring
• work with local community resources including; Meals on Wheels, transportation and caregiver support programs

NOTE: If patient's needs change, so will the care plan, the program was designed with this flexibility in mind * the supports are in place, so the patient has what is needed to stay safely at home * phone contact is available 24 hours a day

After eight (8) weeks, the patient and the care team will review progress and plan for ongoing care. Around 12 weeks, if patient requires ongoing care, the team will help plan for this care. Patient will be referred to Ontario Health atHome services, and their staff will conduct an eligibility assessment for ongoing support and contact patient directly