Scarborough Health Network (SHN) is partnering with Bayshore HealthCare to extend health care services beyond our hospital walls. Through our SHN@Home program, we create and deliver a seamless discharge care plan for patients who require continued restorative care that follows patients into the community after they have been discharged from one of our hospitals.
The program is comprehensive and has been designed with the patient in mind. Through a series of check-ins with the SHN@Home care team, patients can be confident that their journey to optimize their rehab goals is our priority when staying in hospital is no longer required.
How it Works
Your SHN@Home coordinator and team meets with you, your family and your hospital team to go over what to expect and to create your care plan. This will be shared with everyone involved in providing your home care.
Your first home visit will be scheduled before you leave the hospital and you will know the name of the person coming to your home. In some cases you will meet this person before you leave the hospital.
What to expect during your first week at home after discharge:
- You will receive a phone call from a member of your SHN@Home team to make sure that you have arrived home safely.
- Someone from your team will visit you on your first day at home. They will be checking in with you every day of this week.
- After the first week, you and your team will decide how often they need to check in with you.
Your SHN@Home team will work closely with you, your family and our hospital team to make sure your care plan at home meets your needs. This team, consisting of staff from Bayshore and SHN may consist of:
- Care coordinators
- Personal support workers
- Occupational therapists
- Speech-language pathologists
- Social workers
Your team will continue to work closely with you, your family and our hospital team to ensure your goals are being met at home. They will keep your primary care provider (family doctor or nurse practitioner) up to date on your progress.
If you don’t have a primary care provider, SHN@Home will work with you to find one.
Your SHN@Home team will use different ways to check in and care for you:
- Home visits
- Phone calls
- Technology (i.e. telemonitoring)
- Work with other local community resources (i.e. Meals on Wheels, transportation and caregiver support programs)
If your needs change, so will your care plan. There will be times where you may need more or less services. SHN@Home was designed with this flexibility in mind.
These supports are there so you have what you need to be at home.
Frequently Asked Questions
Most patients are part of the SHN@Home program for up to 16 weeks.
If your medical condition changes and you need hospital care, SHN@Home will continue to support you when you return home. Your team will be kept informed and plan for your transition back home.
After 8 weeks: You and your team will review your progress and plan for your ongoing care.
After 12 weeks: Your team will connect you with a Local Health Integration Network (LHIN) Care Coordinator who will conduct an assessment and plan with you for your ongoing care.
After 16 weeks: Your team will connect you with homecare services provided by the LHIN.
For questions or concerns, please contact your SHN@Home team at our 24/7 line: