From Hospital to Home: How One Ontario Health System Is Easing this Transition

Ann Dekker, 89, lived independently before her hospital stay. Although she recovered medically and was ready to be discharged, she still required support to do so safely. 

“All she wanted was to return home, and the support from the Hospital2Home program made her wish possible,” said her son, Ron Dekker. “The team at Lakeridge Health discharged her with a plan to ensure that she continue to receive the right care.”

For families like the Dekkers, Hospital2Home offers comfort, reassurance and a safe transition from hospital to home.

Creating Hospital2Home to meet Patient Needs

While rates are now at their lowest level in a decade, only a few years ago health systems across Ontario were grappling with the same challenge: how to reduce high volumes of alternate level of care (ALC) patients to ease pressure on emergency departments and inpatient units. While ALC patients no longer require acute hospital care, they often cannot be safely discharged because of the lack of appropriate support available at home or elsewhere. In the East Region, Lakeridge Health – one of Ontario’s largest and most integrated community health systems – brought together hospital teams, home care providers and community partners to introduce a short stay bridging program that helps prevent unnecessary hospital admissions and supports a safer, more confident return home.

The program, Hospital2Home, reimagines how transitions to home are planned and delivered, reducing ALC volumes and improving patient flow.

Improving Capacity and Patient Flow

In 2024, ALC cases accounted for nearly 30 per cent of all inpatients at Lakeridge Health. This strained capacity delayed access to hospital beds and resources for other patients and made it harder to provide care in the most appropriate setting.

In collaboration with Ontario Health atHome, Lakeridge Health implemented a more rigorous sign-off process for long-term care placement, invested in a dedicated transition management team and realigned transition management under post-acute care. Lakeridge Health invested in a new role called a “Transition Facilitator.” These care team members support timely, seamless discharges to the community.

“We aligned this work with Lakeridge Health’s continuous quality improvement model by putting the right structures and discipline in place, regular ALC and discharge rounds, clear goals with stepwise targets and a strong focus on community partnerships,” said McLeod. “That approach allowed us to stay nimble, accountable and focused on improvement in a way that others facing ALC pressures can replicate.”

Within a year, Hospital2Home helped reduce the percentage of ALC cases by more than half – from nearly 30 per cent in the summer of 2024 to about 15 per cent a year later and roughly 10 per cent today.

Improved patient flow has also contributed to shorter emergency department waits, faster ambulance offloads and safer care environments – greatly improving patient experience.

“For our family, the compassion and quality of care meant everything and gave us peace of mind,” said Dekker. “We’re incredibly grateful for the team at Lakeridge.”