After three weeks in hospital recovering from a broken back, Marlene Keefe returned home in severe pain, using mobility aids and facing the reality of recovering alone.
Fiercely independent and hesitant to accept help, she wasn’t sure she wanted anyone coming into her home. That is, until she worked with her care team at Health Sciences North to enroll in the province’s Hospital to Home (H2H) program.
“I didn’t think it was for me,” she said. “I like to do things myself.”
Now, she says enrolling was one of the best decisions she made during her recovery. Marlene is one of hundreds of patients benefiting from Hospital to Home, a provincially supported transitional care program that helps patients who no longer require acute hospital care continue their recovery safely at home.
A different kind of recovery
Following discharge, Marlene received an in-home assessment within 24 hours and a personalized care plan tailored to her needs. Through the program, she received regular physiotherapy and personal support in her own home. This care is designed to rebuild confidence, as well as strength.
“Hospital to Home allows us to meet patients where they are, both physically and emotionally,” said Christie Jefferies, Coordinator of the Hospital to Home Program at HSN. “By enabling patients to return home sooner, the program helps them heal with dignity and independence, surrounded by the routines, comforts, and sense of normalcy that are so important to both physical healing and emotional well-being, while avoiding lengthy hospital stays.”
When a secondary leg injury temporarily set her back, Marlene became discouraged. The care team adjusted her plan and focused on reassurance as much as rehabilitation.
“We reassess and adapt care continuously,” Jefferies said. “If a patient has a setback, we adjust. If they’re progressing well, supports taper. That flexibility is critical to safe recovery.”
Living alone, Marlene said the consistency of care made a profound difference.
“They weren’t just workers,” she said. “They felt like friends. I looked forward to them coming.”
Today, she continues her exercises, uses mobility supports safely, and is gradually returning to daily activities. While her recovery is ongoing, she credits Hospital to Home with helping her heal at home with dignity and confidence.
“I was very reluctant at first,” she said. “But I’m so glad I did it.”
Supporting patients and strengthening system flow, Hospital to Home was developed in response to sustained capacity pressures across Ontario hospitals. At HSN, daily occupancy often exceeds 110 per cent, with an average of 644 patients cared for daily in a hospital with 526 inpatient beds. The program enables safe, timely discharge for patients who would otherwise remain in acute care beds while waiting for rehabilitation or community services.
Hospital to Home provides short-term, intensive transitional care, including a 72-hour post-discharge care plan, an in-home assessment within 24 hours, and bundled services through eight- or 16-week care streams, depending on patient needs.
“Hospital to Home has changed how we support discharge and recovery,” said Meghan Forestell, Manager, Access & Flow, Hospital to Home Program. “It provides a clinically appropriate option for patients who no longer need acute care but aren’t ready to recover independently. By transitioning patients home with structured, time-limited supports, we’re reducing Alternate Level of Care pressures, improving access to inpatient beds, and strengthening hospital flow.”
Strong results, meaningful impact
Patient experience data reflects the program’s success:
- 99 per cent patient satisfaction
- 95 per cent overall service rating
- 55 per cent discharged to independent self-care
- 30 per cent transitioned to Ontario Health at Home services
Within three months of implementation:
- ALC volumes dropped from 125 to 92
- Patients waiting for long-term care decreased from 73 to 30
- Patients waiting for inpatient rehabilitation fell from 43 to 21
As of December 2025:
- 361 patients served
- 14,763 home visits and 1,025 patient touchpoints delivered
The program continues to evolve, including the introduction of a four-week intensive rehabilitation bundle to further reduce pressure on inpatient rehabilitation beds. Part of a provincial shift Hospital to Home reflects a broader transformation underway across Ontario. The province has committed more than $1.1 billion to strengthen home care, including targeted investments to expand Hospital to Home models that support safe discharge, reduce ALC pressures, and improve patient flow.
“HSN has received X million from the provincial government to support the Hospital to Home program, and we greatly appreciate that support,” said David McNeil, HSN President and CEO. “We often have 120 to 130 patients in hallways and unconventional spaces everyday. Our hospital has been built too small and needs to grow to meet current and future needs for healthcare in the region. So the support for Hospital to Home is very much needed for HSN and the patients and families from the Northeast who rely on us for care.”
For Marlene, the impact is simple and deeply personal.
“I didn’t want the help at first,” she said. “But it helped me heal, and it helped me feel like myself again.”