What is Southlake@home?
Southlake@home provides you with the care you need at home when you are discharged from Southlake. The Southlake@home team consists of your coordinator, nurses, personal support workers, occupational therapists, physiotherapists, social workers and dietitians. The Southlake@home team works closely with you and our hospital team to make sure your care plan at home meets your needs. Our goal is to make your first weeks at home as easy for you as possible.
How does Southlake@home work?
What happens before I leave the hospital?
Before you leave the hospital, your Southlake@home coordinator meets with you, your family, your hospital team and your Southlake@home team, to create your care plan. This plan will be shared with everyone involved in providing your homecare. 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 happens when I get home?
On the day you are discharged, you will get a phone call from a member of your Southlake@home team to make sure that you have arrived home safely.
Your Southlake@home team will:
- Visit you on your first day at home
- Check in with you every day for the first week
- After the first week, you and your team will decide how often they need to check in with you
- Work closely with the hospital to ensure your goals are being met after you get home
- Keep your primary care provider (family doctor or nurse practitioner) up to date on your progress
- Use different ways to check in and care for you:
- Home visits
- Phone calls
- Technology like telemonitoring
- Work with other local community resources including Meals on Wheels, transportation and caregiver support programs
If your needs change, so will your care plan. You may need more services at times or you may need less. Southlake@home was designed with this flexibility in mind. These supports are there so you have what you need to be at home. There is a 24/7 phone number that you call if you have any questions or concerns when you are home.
How long does Southlake@home last?
Most patients are part of Southlake@home for up to 16 weeks.
What happens if I need to be readmitted to Southlake?
If your medical condition changes and you need hospital care, Southlake@home will continue to support you when you return home. Your Southlake@home team will be kept informed and plan for your transition back home.
What happens if I need ongoing care?
If you need care after 16 weeks, your Southlake@home team will connect you with homecare services provided by Central Local Health Integration Network (LHIN). After 8 weeks, you and your team will review your progress and plan for your ongoing care. Around 12 weeks, if you require ongoing care, your Southlake@home team will help you plan for this care. They will connect you with a LHIN care coordinator who will conduct an assessment and plan with you for your ongoing care.
What if I don’t have a primary care provider (family doctor or nurse practitioner)?
Southlake@home will work with you to find one.