Home At Last Program

As a partnership between hospitals, community support service agencies and the Toronto Central CCAC, this project helps frail older adults without immediate support to arrive home safely upon discharge from hospital and receive follow-up services at home.

This research project is a collaboration of investigators in Ontario, Quebec, and Alberta to support stronger primary care for older adults living with frailty. Effective assessment of frailty will allow older adults to remain in their homes and communities. Primary care clinicians will use the Assessment Urgency Algorithm tool, which uses a scale of one to six, to determine frailty level. This ensures a client is connected to the right type of service, at the right time.

Caredove has configured services to display results in 3 main categories:

  • Prevention & Health Promotion for scores 1 & 2
  • Community Support Services for scores 3 & 4
  • Specialized Geriatric Services for scores 5 & 6
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Funded ByProject Sponsor

Toronto Central LHIN

Network Search SiteAlberta Network Waterloo Wellington Network

Click here to refer to the Home At Last Program.

Lead Agency

West Neighbourhood House



December 2018 project performance

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Refer to the Home At Last Program

An effective referral management system that helps hospitals reduce readmissions by referring to community support service agencies in the Toronto Central region.

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