Description of Services:
Integrated transitional care program designed to support patients in returning home safely and sooner from hospital, while continuing their recovery in the comfort of their own home
The program provides individualized, coordinated care that focuses on recovery, rehabilitation, independence, and overall well-being * depending on patient needs, services may include nursing, physiotherapy, occupational therapy, personal support, social work, speech-language pathology, and other interdisciplinary supports
A Coordinator works closely with patients, families, hospital teams, and community providers to ensure a seamless transition home, timely access to services, and ongoing care coordination
Offers support for up to 16 weeks, with specialized 8-week pathways for Trauma, Orthopaedic, Surgery, and Cardiac patients * these pathways provide targeted rehabilitation and clinical supports tailored to each patient's recovery needs
Goal is to reduce unnecessary hospital stays, prevent avoidable readmissions, and help patients regain their strength, confidence, and independence at home * when needed, patients are connected with ongoing community services to support their long-term well-being
Wheelchair Accessible