“It’s important to connect patients with the right care at the right time to help them maintain their health and avoid future visits to the hospital.”
One way to reduce pressure on our health care system is to prevent the need for hospital visits. Data indicates that a small percentage of the population accounts for the greatest use of hospital services and resources. Addressing the root causes of this trend is important to alleviating pressure on the system and improving community health.
Established in 2014, the Hospital 2 Home (H2H) program provides specialized care for these patients, who are impacted by chronic conditions and face social or economic barriers to achieving good health.
“We partner with patients in their homes and develop coordinated care plans focused on their unique needs,” says Jana Cochrane, Manager of Community and Population Health Services at St. Peter’s Hospital.
No two patients have the exact same requirements, so standardized screening and assessments are utilized to determine the best course of action for each individual.
Improving quality of life
Barriers experienced by this population include poor health literacy, mental-health challenges, frailty, lack of social supports, isolation due to impaired physical/cognitive function, lack of food security, and lack of other basic needs that support health and well-being. Some patients may lack a refrigerator, stove or mattress – things that are often taken for granted by people.
“It’s important to connect patients with the right care at the right time to help them maintain their health and avoid future visits to the hospital,” says Jana. “This might mean referring them to various community services or government programs to help them get on track.”
Using a non-judgmental approach, H2H team members build strong, open and honest relationships with patients to develop and implement plans of care. A relationship of trust must be established in order for patients to fully benefit from the program.
Making a real difference
“We couldn’t do the work we do without the donors who support Hamilton Health Sciences Foundation. Funds that enable us to provide gift cards or food to patients in need can make a world of difference in their lives.”
H2H has been honoured with many awards, including the Minister’s Medal for Excellence in Health Quality and Safety in 2017, and the Canadian College of Health Leader’s 2020 Excellence in Patient Experience Award, among others.
“The most fulfilling part of our work is improving the quality of life for patients and helping when they need it most,” says Jana. “Working with this program brings great joy and purpose to my life. It’s the most rewarding work I’ve ever done.”