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?
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.
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.