What is RVH@home?
Once you qualify for the program, RVH@home provides you with the care and support you need at home when you are discharged from RVH. The RVH@home team consists of your navigator, nurses, personal support workers, occupational therapists, physiotherapists, dieticians, speech language pathologists, and social workers. The RVH@home team works closely with you and our hospital team to make sure your care plan at home meets your needs.
Before you leave the hospital, your RVH@home Navigator and Service Provider will meet with you, your family, your hospital team, and your RVH@home team to create your first 72 hours care plan. This plan will be shared with everyone involved in providing your in-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.
On the day you are discharged, you will get a phone call from a member of your RVH@home team to make sure that you have arrived home safely.
Your RVH@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
- Complete your on-going care plan
- Use different ways to check in and care for you:
- Home visits
- Phone calls
- Work with other local community resources including Meals on Wheels, transportation and caregiver support programs – if needed.
If your needs change, so will your care plan. You may need more services at times, or you may need less. RVH@home was designed with this in mind. The RVH@home 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.
The RVH@home program lasts up to 16 weeks.
If your medical condition changes and you need hospital care, RVH@home will continue to support you when you return home. Your RVH@home team will be kept informed by your hospital team and will be involved in updating your care plan in preparation of your transition back home.
If you need care after 16 weeks, your RVH@home team will connect you with homecare services provided by Ontario Health. 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 RVH@home team will help you plan for this care. They will connect you with a Home and Community Care Support Services care coordinator who will complete an assessment and plan with you for your ongoing care.