Abstract
Background: The Couchiching Health at Home (CHAH) program is a comprehensive sixteen-week restorative rehabilitation program that offers in-home services, provided by Personal Support Workers (PSW’s), nurses or therapy providers. The first 30 days of the program are provided by CHAH hospital staff to facilitate immediate discharge and return to the home environment when ready to leave hospital.
Approach: The CHAH Hospital to Home program supports the immediate discharge from hospital and return to a home environment as soon as they are deemed to be ready to go home. Continuity of care and rehabilitation is maintained by PSWs, nurses or therapy providers employed by the hospital who are able to support the patient within their home environment. A customized care plan is created to facilitate communication between providers and organizations regarding the patients rehabilitation plan. The CHAH program works in partnership with two service provider organizations to facilitate seamless transitions to care following the initial 30 days and Ontario Health atHome if ongoing care required after 16 weeks. Many patients are discharged from the program during the 16 weeks but for those that require on-going support and care they are transitioned to Ontario Health atHome or LOFT community services.
Results: CHAH continues to expand and has exceeded targets for the last 2 years. In 2024 CHAH exceeded the annual target of 150 patients by the end of Q1. The CHAH model supports timely discharge from hospital to reduce the number alternate level of care days (ALC) and get patients home sooner. Our model includes a Nurse Practitioner (NP) for episodic care for unattached patients which supports a decrease in return visits to the Emergency Department (ED) as the NP provides follow up on all blood work, diagnostics, and coordinates house visits as needed. The CHAH program has provided over 10,000 hours of care in Q1 and Q2 of 2024 and we anticipate this continuing to grow as the program continues to expand.
Implications: The CHAH program is available to all patients in the Couchiching region who require home support to facilitate rehabilitation. The program supports patients being discharged from the hospital but also works to divert hospital admissions if the CHAH program can provide the support needed in the community through community or Emergency Department referral. The customized care plan supports person centred care by facilitating continuity and communication. We will highlight lessons learned in the development and implementation of the program and opportunities for expansion and further collaboration.