Imagine for a moment that you’ve been in the hospital for a long stay after a complicated surgery. Once your surgeon gives the all-clear for you to head home, you have limited support and are making frequent calls to your physician to make sure you are recovering smoothly.

Now, imagine an alternative possibility. After your hospital stay, a specialized team of healthcare professionals look after you at home. Maybe a personal support worker visits to help you bathe or make breakfast, or a nurse comes to check on your vitals and dress your incision. These home care specialists are also in touch with the care team at the hospital, so you can safely recover from the comfort of your own home.

With VHA Home HealthCare’s Lead Home Care Agency Model, this possibility has already been made a reality for many patients.

VHA first began exploring this model in 2019 when the University Health Network (UHN) approached VHA about a partnership for their Integrated Care (IC) program. The program provides an evidence-based model of care aimed at improving the client, caregiver and care provider experience. In collaboration with UHN, VHA’s role as Lead Home Care Agency enables clients to have a seamless care experience transitioning from hospital patients to home. Once clients are in stable condition at the hospital, they can be sent home with additional support from VHA care providers, freeing up space in the hospital while allowing clients to be where they are most comfortable.

Jennifer Chen, visiting nurse at VHA, works within the Lead Home Care Agency model, visiting clients in their homes across the Greater Toronto Area. She witnesses the positive client outcomes seen as a result of this program on a daily basis.

Jennifer Chen, VHA Nurse

“We are the eyes and ears of physicians and surgeons once our clients return home from hospital,” says Jennifer. “Most clients need instruction and assurance so they can properly rest and relax for an effective recovery.”

Care providers like Jennifer provide care to both medical and surgical patients. The current medical population is General Internal Medicine clients including those with Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and COVID+ care needs. The team also provides care to thoracic, vascular, cardiovascular, orthopedic, and most recently transplant surgical clients. In-home services can include nursing care, personal support, occupational therapy, physical therapy, speech language pathology, social work and dietetics, respiratory therapy, or a combination of several. These services are customized to meet the unique needs for each client.

As Lead Home Care Agency, VHA co-designs these pathways with their hospital partners and coordinates the care schedule. VHA also oversees a 24/7 program phone line, which provides clients and their families access to a Program Assistant and On-Call Nurse after hours, weekends and holidays.

“Given the complex nature of many of these complicated surgeries and conditions, people I see are often struggling with pain and they are anxious about their symptoms. Clients are always very relieved to have the opportunity to ask questions,” says Jennifer.

VHA also supports digital tools to ensure both the home care and hospital providers have shared medical records so they can easily communicate patient information as needed.

“Our team reports anything that is concerning to our hospital care team partners, where they can involve the client’s physician or surgeon if needed for further instruction,” she adds.

 

Mary Osagie, VHA PSW

In the program’s current model with UHN, clients receive service at home for up to 90 days after hospital discharge. And although this time may fly by for some, according to Personal Support Worker (PSW) Mary Osagie, by the end of the program, the bonds and memories between care provider and client can last a lifetime.

“Clients often tell me stories about their life. It’s amazing that as home care providers we can build those connections over 90 days and really make a difference,” says Mary.

“As a PSW, you help clients understand that everything is going to be okay and that they will heal. I’ve been a PSW for many years, but I’ve never provided care through a unique program like this before,” she added.

The integration of care through VHA’s Lead Homecare Agency model means that the entire care team across sectors and organizations work together and put clients at the centre to ensure a seamless, high-quality experience is delivered for each and every hospital-to-home transition.