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

Funded ByProject Sponsor

Toronto Central LHIN


  • Reintegration Care Units (RCU)
    These units support patient transitions from the hospital to short-term transitional care units in the community that provide a safe and supportive place to help patients increase strength, mobility and endurance to support their transition home or into an alternative care setting.
  • Caregiver ReCharge Programs
    These programs provide caregiver relief and improve their capacity to transition their loved one home and continue to provide care for the client while promoting their own wellbeing.  These services include in-home respite (day/night), away from home overnight respite, and/or supervised programming in a group setting during the day (i.e. Adult Day Programs).
  • The Process
    The Centralized Referral Management Team members will confirm eligibility and the client will be matched to a health service provider (of the selected program) by their unique needs and availability, with consideration given to geography where possible.
    The Health Service Provider Team members will then work with the caregiver and/or the clients’ families on a plan for service provision.
  • Sites
    Bellwoods, Hillcrest Reactivation Centre, LOFT Community Services, Pine Villa Sprint, Reconnect Community Health Services, Rekai Centre Transitional Care Unit, St. Hilda’s Towers Senior Care Unit, The Neighbourhood Group


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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