In The Home: Home at Last (HAL)
A Smooth Transition From Hospital To Home and Community!
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Home At Last (HAL) is a free service that provides help to older adults to settle in at home after being in the hospital. HAL identifies seniors in local hospitals who have limited supports upon discharge or potential concerns regarding how well they may settle when they return home.
Learn more about HAL by watching this video!
- Features & Benefits
- Eligibility
- Cost
- HAL Process
- Partners
Home at Last (HAL) is a program designed to work collaboratively with the Hospitals, Community Support Service Agencies and the CCAC to help transition older adults home from hospital and safely settled.
- There is no cost to the client.
- Facilitates a safe and timely discharge from hospital to home.
- Coordinates services for a smoother transition of clients from hospital to community.
- Improves client discharge experience and client health outcomes using the Client Driven Care approach.
- Improves vulnerable client access to ongoing community support services.
To register or for additional information contact Lesley Brown RPN, HAL Supervisor at 1-877-502-8277 ext 2203.
HAL is available to individuals 55 years of age and older. (Clients under 55 can be considered on a case by case basis).
Clients must live in Huron or Perth County.
Clients must be medically stable.
- HAL is eligible to residents of retirement homes and Long Term Care facilities.
- Day surgery or elective surgery clients requiring support when they go home the same day can access HAL.
- Service is available to clients having procedures that require sedation.
- HAL can be used for clients who require CCAC-PSW support on the day of discharge from the hospital.
- Clients do not need to be using CCAC services after discharge.
There is no fee for this program.
This program is funded through the Aging at Home initiative through the South West Local Health Integration Network.
- Referrals are set up with the Discharge CCAC Case Manager at the hospital OR by contacting the HAL Supervisor.
- It is ideal if referrals are set up the day before, however same day referrals can generally be accommodated.
- Referrals are taken Monday to Friday between the hours of 8:30 am to 4:15 pm.
- Weekend discharges are possible if set up by Friday at 4:00 pm.
- The HAL Supervisor links with the Community Support Service agency to arrange for services, example, transportation and Personal Support Worker.
- The Personal Support Worker (PSW) will meet the client at the hospital or at home.
- PSW can stay for up to four hours with the client.
- Safety assessment of the home is completed.
- Groceries or prescriptions can be picked up by PSW.
- PSW can assist with personal care, light housekeeping or laundry.
- A complimentary meal (Frozen Meals on Wheels) is provided for each client.
- The PSW will review the Community Support services available to the client in their community.
- The PSW provides a verbal report to the HAL Supervisor.
- Once the client is settled at home they will receive a follow up call by the HAL Supervisor within 24 to 48 hours.
- If indicated a referral will be made to a Community Support Service agency for ongoing supports.
- The HAL Supervisor will contact the CCAC if identified that additional support is needed.
- If additional services are required the HAL Supervisor will follow up with the client one week later to ensure proper contact has been made.
Home at Last is provided in Partnership with:
- St Marys & Area Home Support Services
- Community Outreach Milverton
- Mitchell & Area Community Outreach
- VON Huron Perth
- South West Community Care Access Centres - Huron & Perth
