Hospital at Home

The Hospital at Home (H@H) pilot project provides enhanced medical and clinical management for patients rostered to the Prince Edward Family Health Team (PEFHT) who are experiencing escalating difficulty managing and are at imminent risk of hospitalization. Patients must require services that exceed the plan of care that is currently available from the Community Care Access Centre (CCAC). The PEFHT H@H pilot program is the first rural program to provide the equivalent of hospital based care, in the patient's home setting.

H@H patients must have a valid OHIP number, be rostered with the PEFHT and must be a palliative care or frail elderly patient, including those with dementia. Patients and caregivers must consent to admission to the H@H and to consider participation in the research aspect of the program.

The goals of the Hospital at Home program are to support patients and caregivers in the home, to facilitate early discharge from QHC PECM and to support repatriation from secondary or tertiary hospitals, back to the community setting. Based on physician assessment and caregiver discretion, patients may be managed in their own home or assisted living settings such as Long Term Care Homes or Retirement Homes. Patients receive comprehensive nursing visits that are patient centered, not time limited or task oriented; and will receive priority access to all PEFHT clinical programs and be connected to relevant Community Support Services.

The objectives of the Hospital at Home program are:

  • to provide patients with high quality healthcare, equivalent to hospital based care, with the benefits of remaining in their own home
  • to avoid repeat hospital visits or stays
  • to maximize Family Health Team resources in partnership with the CCAC and QHC
  • to provide a cost beneficial alternative to hospitalization

Services provided through the H@H Program:

  • up to 4 hours of scheduled nursing care daily utilizing full scope of practice
  • up to four daily Personal Support Worker (PSW) visits working to their full scope of practice
  • priority access to Physiotherapy and Occupational Therapy services
  • daily interdisciplinary team meeting , in person or virtually, to review care plan
  • up to twice daily comprehensive physical assessment
  • initial plan of care for up to 7 days with the option of extension for 7 days at the discretion of the team
  • daily effective communication between team members
  • daily actual or virtual MD home visit as required
  • daily contact with Team Leader
  • follow-up contact with H@H post discharge

By strengthening home support services for frail elderly and palliative patients and their caregivers, we see increased confidence in their ability to manage at home. By increasing knowledge of their health related issues and care options, we can increase quality of care and quality of life, for both the patient and caregiver. The addition of leading edge technology for regularly scheduled home visits optimizes time and cost efficiency. With the enhanced integration of community support, home care, hospital and Family Health Team services, we will see a decrease in hospital admissions, length of stay and ER visits.

Ask your Primary Care Provider for details and referral information.

Links of Interest:

Quinte Health Care, Primary Care Services

Saint Elizabeth Home Service

South East Community Care Access Centre

Contact Information:The Hospital at Home Team includes:

Geri Claxton, RN Team Leader
Brad Gunn, Nurse Practitioner
Kate Martin, Administrative Assistant
613-476-2181, ext 4718.

Hours of Operation:
Monday to Friday, 8:30am to 4:30 pm

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