Abstract
Across Ontario hospitals, in patients is readmitted within one month of being discharged from hospital, with older patients being more likely to return than younger patients (Canadian Institute for Health Information, 2022). One contributing factor is the lack of timely access to healthcare services. Bayshore HealthCare, Integrated Care Solutions (ICS) division, is supporting hospitals in Ontario to provide innovative bundled home care programs which aim to reduce emergency department (ED) readmissions and provide mental health, addictions and behavioural supports. These patient-centered programs provide transitional care to patients aiming to stabilize and optimize their recovery while connecting to community supports.