“He thrived because of this care.”

Ethel McGuire has lived in the same East Toronto apartment building for 30 years. For the last 25, she has been the building manager. For Ethel, looking out for the seniors in the building is a natural part of her role.

“Just over eight years ago, when I hadn’t seen Mr. Carter in a few days, I followed up and found him on his bedroom floor unable to get up,” Ethel says of one of the building residents.

“When he went into hospital, I asked if there was anyone he wanted me to call and he said there was no one. We kind of adopted one another at that point.”

Mr. Carter was recently enrolled in MGH2Home, an enhanced care program from East Toronto Health Partners (ETHP), the Ontario Health Team (OHT) serving East Toronto, that helps patients transition home safely when they leave Michael Garron Hospital (MGH) in Toronto’s east end.

Patients in this program are assigned a dedicated team of healthcare professionals from VHA Home HealthCare (VHA), Spectrum Health Care and WoodGreen Community Services, who work collaboratively as an interprofessional team. All of these organizations, including MGH, are members of ETHP.

Each patient’s team includes a nurse who can connect with the patient’s primary care doctor. The team may also include occupational therapists (OT), pharmacists, social workers, personal support workers (PSW) and more.

Together they assess the patient’s needs and collaboratively develop and deliver a customized care plan of services for up to 90 days based on the individual needs of the patient.

Diverse team provides comprehensive care

“The OT, PSW and nurse that were assigned to Mr. Carter seemed to be the perfect fit,” Ethel says.

“It took a lot for Mr. Carter to admit he required the extra help, but he came to welcome it and I believe he thrived because of this care.”

“One of the benefits of MGH2Home is the functional exercise program we are able to offer with the support of OT assistants (OTA) and physiotherapy assistants (PTA),” notes Jeanie Lee, supervisor for the program from VHA.

“In home care, we often see patients who have reduced mobility following a hospital stay due to the time spent in bed. OTAs and PTAs support MGH2Home patients with an exercise mobility program to help them get stronger, which supports their transition home.”

A main goal of MGH2Home is to help patients and their care providers safely manage care needs at home, in turn reducing unnecessary emergency room visits and re-admissions to hospital. The program has made a difference for over 105 patients since its launch April 17, 2023.

“When patients are discharged from the hospital, we want to help ensure they can remain safe and healthy out of hospital,” says Dorothy Quon, Director of Emergency Health Services at MGH.

“This helps improve their health outcomes and ensures hospital emergency departments have capacity to continue providing care for urgent, life-threatening health issues, especially as we approach respiratory illness season.”

Collaboration key to success

Naushin Chauhan, one of the MGH2Home primary nurses from Spectrum Health Care, believes one of success factors of the program is the collaboration of the interdisciplinary care team.

This allows the team to holistically address patients’ care needs, including those that go beyond physical health.

Jhenelle Grey, a social worker from WoodGreen Community Services who helps connect MGH2Home patients with community resources, agrees.

“Our ‘one team’ approach means we problem solve together so we can respond quickly to any changes in a patient’s situation and provide more timely access to services,” Jhenelle says.

“I’ve heard from many patients and their caregivers that they appreciate how coordinated the care is. And it also improves my experience as a healthcare professional, as I can learn from colleagues with different specialties.”

“I would agree that a great benefit to this program is the collaborative team approach,” Jeanie adds. “Patients tell us they feel supported and working as “one team” helps the providers feel supported as well.

“I totally appreciate the MGH2Home service,” Ethel adds. “Communication with the team is definitely key.”

MGH2Home is an important step in ETHP’s efforts to integrate care in East Toronto and to support more patients at home, where they most want to be.