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.