When patients are discharged from hospital, there can be a lot of emotions. On one hand, returning home can be a huge relief, but on the other hand, it can raise feelings of apprehension and nervousness. They might worry that they won’t be able to do all the things they used to do once they are at home, or they may worry about re-injuring themselves. Thankfully, VHA Home HealthCare (VHA)’s Homecare Specialists and interprofessional teams can help with this transition, providing care that is uniquely planned to address the specific needs for each patient.

After a traumatic fall, Bella received expert acute care at Sunnybrook Health Sciences Centre. When it was time for Bella to be discharged home, she transitioned to care through the Sunnybrook-to-Home program with VHA as homecare partner, helping to ensure Bella received the expert care she needed to continue recovering at home.

Bella lives independently and had some concerns about returning home after the bad fall that took place in her bathroom. Since her mobility was limited as she healed, she feared another fall might occur if she attempted to bathe alone.

A VHA Homecare Specialist completed a comprehensive in-home assessment of Bella’s needs and a team of homecare providers were added to her care plan.

“Taking a shower was a big issue for me,” Bella shared. “But they were there to stay with me and help me. After a while, I was able to shower by myself, but when I came out, they helped me get ready for the day. They were there to see that I wasn’t on my own.”

Homecare Specialists are a client’s direct point of contact at VHA, a dedicated care partner who is focused on the individual needs of each client in the Sunnybrook-to-Home program. They maintain communications with primary care providers and align care plans through shared visits and joint case reviews.

For clients like Bella, the Sunnybrook-to-Home program makes the transition from hospital to home smoother and safer. Once each client is paired with a Homecare Specialist, the right mix of services is coordinated for up to 16 weeks after discharge, ensuring no one has to navigate recovery alone.

The program also builds in vital checkpoints along the way. In addition to customized plans for the first 72 hours at home, which is often critical for a safe transition of care at home a mandatory check-in with the client’s primary care physician takes place within seven days of leaving the hospital to make sure recovery stays on track.

“At Sunnybrook, helping patients feel safe and supported as they return home is at the heart of the Sunnybrook-to-Home program. Working with our partners at VHA allows us to make sure every patient gets the right care at the right time. We’re so happy to hear that Bella’s transition home went smoothly and that the program made a difference in her recovery,” says Hend Al-Fayez, Interim Program Manager, Community Integration, at Sunnybrook.

“For VHA, it’s about being there through every step of the journey. Our interprofessional teams take great pride in caring for our shared patients, ensuring they feel supported and safe as they transition home,” says Hemjot Mal, Senior Director overseeing the design and operations of the program at VHA.

VHA is pleased to contribute to successful recoveries for Sunnybrook-to-Home patients, like Bella, in the comfort of their own home.