NGH@Home

Your NGH@Home team consists of (but is not limited to) your NGH patient navigator, nurses, personal support workers, occupational therapists, physiotherapists, speech language pathologists, dieticians, social workers and community partners.

Your NGH@Home team will work closely with you, your family, and your hospital care team to create a coordinated plan and set mutual goals for your recovery.

Before you go home your NGH@Home navigator will meet with you and your hospital team to identify your unique care needs and create a plan for discharge. They will schedule your first home visit so you know who is coming and when, and your care plan will be shared with everyone involved in your home care.

On the day you leave the hospital you will receive a call from a member of the NGH@Home team to make sure you arrived home safely.

Your NGH@Home team will:

- Visit you at home soon after you leave the hospital

- Check in with you regularly to see how you are doing

- Adjust your care plan with you as your needs change

- Work closely with the hospital team to ensure mutual goals continue to be met

- Keep your primary care provider up to date on your progress

- Use different ways to connect with you, such as home visits, phone calls, and telemonitoring

- Link you with local community resources, such as meal programs, transportation, and caregiver support

If your needs change, your care plan will change as well. At some times you may need more services and at other times you may need less, NGH@Home will titrate your services based on your unique recovery. Your team will monitor your progress and contact your primary care provider if any concerns arise.

The NGH@Home program lasts from 8-16 weeks depending on your unique needs and progress. If you require care after 16 weeks, your NGH@Home team will help connect you with services provided by Ontario Health.

If your medical condition changes and you need hospital level care, your NGH@Home team will stay informed throughout your stay to help support a smooth transition when you are ready to return home.

If you do not have a primary care provider it will not affect your eligibility with NGH@Home, we can help get you started with Health Care Connect so you can apply to be matched with a new physician or nurse practitioner.

If you are currently enrolled in NGH@Home and have questions or concerns, you can contact our service partner, Bayshore HealthCare, anytime at 1-866-697-4523.

For general questions about the NGH@Home program, or to learn more, please contact the NGH Patient Navigator, Michelle Hoyle, at 226-931-2774 or mhoyle@ngh.on.ca.
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NGH@Home supports Norfolk General Hospital patients who are medically stable and can safely participate in short term monitoring, therapy, or treatment at home. Eligibility is based on an in hospital clinical assessment and Ontario Health criteria.

For steps on how to refer a patient, contact the NGH@Home Patient Navigator Michelle Hoyle or the unit Clinical Practice Leader. Internal information can also be provided to support referral decisions.