The transition from a hospital bed back to the familiar surroundings of home often represents a critical and vulnerable period in a patient’s recovery journey. Hamilton Health Sciences has introduced a groundbreaking program, HHS@Home, that fundamentally rethinks this transition by bringing comprehensive, hospital-level medical services directly into the community. This innovative model is specifically designed for individuals who are medically stable enough to leave an acute care setting but still require substantial medical and social support to ensure a safe and effective recovery. By extending high-quality, integrated care beyond the hospital’s walls, the initiative addresses two of the most pressing challenges in modern healthcare: alleviating the significant capacity pressures on hospitals while simultaneously enhancing patient outcomes and satisfaction by allowing them to heal in the comfort of their own homes. This strategic shift represents a significant step forward in patient-centered care delivery.
A Patient-Centered Approach in Action
The transformative power of this new care model is powerfully illustrated by the experience of Mary-Jane Dolbear, an 85-year-old piano teacher who faced a long road to recovery after a serious fall left her with broken bones and a head injury. Anticipating a prolonged stay in a traditional hospital setting, she instead became one of the inaugural participants in the HHS@Home program. Her sentiment, “I never imagined I could get this level of care at home,” captures the essence of the program’s impact. For 16 weeks, at no personal cost, she received intensive support from a multidisciplinary team that included nurses, physiotherapists, and personal support workers, all in her own living space. The program also coordinated the delivery and setup of specialized medical equipment essential for her safety and mobility. The care plan was holistically designed, addressing not only her immediate injuries but also her pre-existing arthritis to build her long-term strength and stability, ultimately enabling her to resume teaching piano from her home during her recovery.
HHS@Home is built upon a collaborative framework, led by Hamilton Health Sciences with in-home services expertly delivered by community partner Bayshore Integrated Care Services. This partnership ensures patients receive a broad spectrum of services tailored precisely to their individual needs. The multidisciplinary team available for home visits comprises a wide range of professionals, including nurses, personal support workers, occupational and physical therapists, respiratory therapists, dieticians, and social workers. A cornerstone of the program’s success is its provision of essential medical equipment for the first 30 days following discharge. Items such as commodes, walkers, and bath chairs are supplied to patients, removing a significant logistical and financial barrier that can often delay a safe discharge or lead to preventable accidents at home. This comprehensive, wrap-around support structure ensures that patients are equipped with both the clinical expertise and the physical tools necessary for a secure and confident transition back to independent living.
Redefining Hospital Discharge and Systemic Impact
The seamless execution of this intricate care model is managed by HHS@Home Navigators, who serve as the central coordinators for the entire process. Stationed at Hamilton General Hospital, these navigators work closely with inpatient care teams, patients, and their families to conduct thorough needs assessments. From there, they orchestrate the full suite of services required, coordinating with community providers like Bayshore to ensure everything is in place before the patient even leaves the hospital. This proactive approach effectively resolves one of the most persistent challenges in hospital discharge: the scramble to secure follow-up appointments, in-home support, and necessary equipment. By bridging this logistical gap, the navigators ensure a smooth and uninterrupted continuation of care, providing peace of mind to patients and their families during a critical time and laying the groundwork for a successful recovery from day one of their return home.
From the vantage point of clinicians within the hospital, the program has been a welcome and transformative innovation. Meaghan Myers, a physiotherapist in the spine and orthopedic unit at Hamilton General Hospital, frequently refers patients and describes the initiative as a “rehab program at home.” She emphasizes its value as a crucial “off-ramp for people who have been waiting for rehab or can recover at home,” allowing them to bypass long waits for specialized facilities. This model enables patients to begin intensive therapy immediately after being discharged, a period when their rehabilitation needs are often at their peak. Furthermore, the care plans are dynamic, evolving over the 16-week program duration to adapt to the patient’s progress and align with their personal recovery goals. This flexibility ensures that the care provided remains relevant and effective, maximizing the potential for a full and timely recovery while empowering patients to take an active role in their own healing process.
A Blueprint for Future Healthcare Delivery
Since its launch in late 2024, HHS@Home has facilitated the successful discharge of over 500 patients, generating a profoundly positive and measurable impact on the regional healthcare system. The program directly confronts the persistent issue of Alternate Level of Care (ALC), where patients occupy acute care beds while awaiting necessary discharge supports. By creating a safe and effective pathway for these patients to return home sooner, the program has freed up valuable hospital beds for individuals with more acute medical needs. The data has also shown compelling clinical outcomes, with a demonstrable reduction in patients returning to the emergency department and a lower rate of hospital readmissions. Nate VandenDool, the program lead, highlights this dual benefit, noting that the initiative not only fulfills the widespread patient preference for receiving care at home but also provides a vital tool for managing the capacity challenges facing acute care hospitals, marking a “transformational opportunity” for innovative care delivery.
The development and implementation of HHS@Home were carried out under the direction of Ontario Health, ensuring the program was fully aligned with provincial objectives to modernize home care, reduce hospital congestion, and improve the overall patient experience. Its initial success within the General Internal Medicine units at Hamilton General Hospital paved the way for a strategic expansion into other departments, including surgical units. Looking ahead, concrete plans were established for a further rollout at the Juravinski Hospital and Cancer Centre in 2026. This deliberate growth positioned HHS as a leader in creating an integrated, community-based healthcare system. The program’s philosophy extended beyond a simple discharge process; it was fundamentally about “ensuring we have the right care in the right place, at the right time,” delivered in a seamless and supportive manner that ultimately redefined what was possible for patient recovery outside of traditional hospital walls.
