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GBGH@home

GBGH@home

What is GBGH@Home?

GBGH@Home provides you with the care and support you need at home when you are discharged from GBGH. The GBGH@Home team consists of your navigator, nurses, personal support workers, occupational therapists, physiotherapists, dieticians, speech language pathologists, and social workers.

The GBGH@Home team works closely with you and our hospital team to make sure your care plan at home meets your needs.

How does GBGH@Home work?

Before you leave the hospital, your GBGH@Home team and home care provider will meet with you, your family, your hospital team, and your GBGH@Home team to create your first 72 hours care plan. This plan will be shared with everyone involved in providing your in-home care. Your first home visit will be scheduled before you leave the hospital.

What happens when I get home?

On the day you are discharged, you will get a phone call from a member of your GBGH@Home team to make sure that you have arrived home safely.

Your GBGH@Home team will:

  • Visit you within 24 hours of your return home
  • Check-in with you every day for the first week
  • After the first week, you and your team will decide how often they need to check in with you
  • Work closely with the hospital to ensure your goals are being met after you get home
  • Keep your primary care provider (family doctor or nurse practitioner) up to date on your progress
  • Complete your on-going care plan
  • Use different ways to check in and care for you
    • Home visits
    • Phone/video calls
  • Work with other local community resources including Meals on Wheels, transportation and caregiver support programs – if needed.
If your needs change, so will your care plan. You may need more services at times, or you may need less. GBGH@Home was designed with this in mind. The GBGH@Home supports are there so you have what you need to be at home. There is a 24/7 phone number that you call if you have any questions or concerns when you are home.

How long does GBGH@Home last?

The GBGH@Home program lasts up to 16 weeks.

What happens if I need to be readmitted to GBGH?

If your medical condition changes and you need hospital care, GBGH@Home will continue to support you when you return home. Your GBGH@Home team will be kept informed by your hospital team and will be involved in updating your care plan in preparation of your transition back home.

What happens if I need care after the 16 weeks?

If you need care after 16 weeks, your GBGH@Home team will connect you with homecare services provided by Ontario Health. After 8 weeks, you and your team will review your progress and plan for your ongoing care. Around 12 weeks, if you require ongoing care, your GBGH@Home team will help you plan for this care. They will connect you with a Home and Community Care Support Services care coordinator who will complete an assessment and plan with you for your ongoing care.