The CANES at Home program provides augmented in-home personal support worker (PSW) services for up to 60 days to help patients who no longer require hospital care to receive the care they need in the community.
This Halton Healthcare led initiative, through CANES Community Care and supported by the Mississauga Halton LHIN Home and Community Care, offers a solution to enable patients to return home to await their long-term destination. This may include a long-term care home, retirement home, alternate care setting or home with Home and Community Care supports.
The CANES at Home program is a specific, time-limited, program. Patients will, based on assessed care needs, have access to enhanced PSW supports in the home, provided exclusively by CANES Community Care. Service levels will vary for each patient, depending on customized care plans developed by a Mississauga Halton LHIN Home and Community Care, care coordinator.
The Mississauga Halton LHIN and Halton Healthcare are collaborating with CANES Community Care to identify eligible patients in all Halton Healthcare hospital locations for the program. They will assess patient care needs, develop and share a customized care plan with patients and families, and will coordinate services for patients before they leave the hospital. A Mississauga Halton LHIN Home and Community Care, care coordinator will follow the patient’s progress at home and will continue to assess the patients’ health needs, and continue care planning for up to 60 days.
The community care coordinator will work with patients and families to tailor services to ensure that all care needs are met through existing programs and services after the 60 days has ended. This may include additional choices for long-term care homes, entering into an agreement with a retirement home, or support at home by a community care coordinator with existing LHIN Home and Community Care services and programs.
Benefits to Patients and Families
- Patients will be able to await their long-term destination within the comfort of home with augmented PSW supports
- A community coordinator will support the transition from hospital to home
- Close communication between patients, families and providers in the circle of care
- Customized and flexible care planning that is adjusted to meet the needs of patients and their families
Wrapping Up
The CANES at Home program is up to 60 days in duration, based upon ongoing assessment. Some patients will transition to their long-term destination during this time, while others may continue to require Home and Community Care services. After 60 days or earlier, if patients progress well, PSW services will decrease in volume and/or intensity, and the community care coordinator will transfer the patient’s care to traditional Home and Community Care at the Mississauga Halton LHIN.
Please call 416-743-3892 ext 234.
