Photo caption: (left to right) HEART@Home Navigators Kamaldeep Kalra and Sara Kirkup with a patient.
By: Shahana Gaur, Senior Writer/Communications Specialist, Humber River Health
Humber River Health (Humber) is committed to delivering comprehensive, quality care closer to home. Programs like HEART@Home and Hospice@Home advance this strategic direction by embodying innovative, integrated models of care with a focus on seniors. By creating seamless transitions and addressing population health, these initiatives deliver better outcomes for patients and greater efficiency across the system. As acute care is the most costly part of health care, sustainable models that reduce hospital reliance are essential. Humber’s approach shows how integrated care can ease pressures on acute care while improving the experiences of patients and caregivers alike.
Humber serves the Northwestern Toronto community, which has the highest number of seniors over the age of 80 in Ontario, a number expected to double by 2036. This community is shaped by unique demographics: 23% of seniors live alone, 60% of residents identify as racialized, 54% are immigrants, 52% of adults aged 25-64 do not hold a certificate, diploma, or degree, and both unemployment and labour force non-participation rates are higher than the provincial average. It also has one of the highest material deprivation scores compared to other Ontario Health Teams, further underscoring the need for innovative and equitable models of care.
HEART@Home
HEART@Home is an integrated hospital-to-home program that supports timely patient transition out of hospital into the community, while receiving 16 weeks of intensive support at home. Built on Humber’s HEART (Humber’s Elderly Assess and Restore Team) philosophy and delivered in partnership with the Northwestern Toronto Ontario Health Team and community agencies, including Lumacare, SE Health, LOFT, Reconnect, Circle of Care and Canadian Red Cross - Etobicoke, the program provides wraparound care tailored to the individual. Specifically, through their partnership with LOFT, patients with responsive behaviours and their families receive individualized support. As these behaviours can often delay discharge and add to caregiver burden, having LOFT expertise embedded within the program brings tremendous value.
The HEART@Home team includes navigators, care coordinators, nurses, personal support workers, occupational and physiotherapists, speech therapists, social workers, and dietitians. Together, they design personalized discharge plans that address both medical and social needs, from managing medications and mobility to ensuring access to nutritious meals and transportation. A flexible “comfort fund” helps cover essential supplies such as incontinence pads or transportation to medical appointments, as well as meal delivery costs that can otherwise become barriers to recovery.
“HEART@Home is more than a transition and discharge support program, it is about equity and dignity,” says Beatrise Edelstein, Vice President, Post-Acute Care and Health System Partnerships. “By integrating hospital, home care, and multiple community providers, we are able to respond to the realities of our neighbourhoods and ensure that patients and families are supported well beyond hospital walls.”
Since its launch in December 2020, HEART@Home has transitioned nearly 930 patients and is on track to support up to 400 more in the 2025/26 fiscal year. In just the past two years alone, the program has saved over 8,000 alternate level of care (ALC) days, the equivalent of creating more than 22 additional hospital beds, while freeing up acute care capacity and ensuring patients receive the care and supports at home.
One HEART@Home patient, an older adult widow admitted after a fall and infection, lived alone and did not speak English. While her children supported her, they worried about leaving her alone overnight. Upon discharge, she received coordinated nursing care, wellness checks, physiotherapy, and personal support that even extended into her retirement home once she transitioned. Her care team supported her both medically and emotionally, even helping her bring her beloved cat along to her new residence.
Through the program, she regained independence in daily activities, improved her mobility, and adjusted to her new living situation with confidence and dignity. Her family expressed gratitude that she could move safely from hospital to home, then into retirement living, without the stress of fragmented care.
“Stories like this show the impact of HEART@Home,” reflects Denise Scott, Program Director, Post-Acute and Reactivation Care Centres. “We are bridging patients through one of the most vulnerable moments in their lives, reducing hospital readmissions, and helping families feel supported in the process.”
Hospice@Home
Building on the success of HEART@Home, Humber launched an innovative and integrated program Hospice@Home in 2024, in partnership with Dorothy Ley Hospice, Ontario Health at Home, and Etobicoke Services for Seniors. The program provides individuals with life-limiting illnesses the chance to remain at home with high-quality palliative care, rather than facing prolonged hospital stays.
The model integrates Ontario Health’s home-based palliative funding with hospice and community services. Patients and caregivers receive 24/7 support from a team that includes palliative care physicians, nurses, social workers, spiritual care providers, and volunteers. The program also extends practical supports such as personal care, meals, transportation, and medical supplies.
“Hospice@Home is not just about end of life, it’s about supporting patients and families throughout their palliative journey, with a focus on quality of life,” says Kathleen Kirk, Manager of the Schulich Family Medicine Teaching Unit and Integrated Care Services. “This honours their wishes while also easing pressure on our acute care system by allowing patients to receive the right care in the right place.”
The program’s first year (2024-2025) has shown outstanding results:
97% transition rate into services
0 ALC days for identified patients
76% of patients able to pass away in their preferred location
100% of patients received system navigation and psychosocial support
83% of helpline calls prevented an emergency visit
The success of Hospice@Home has reached international recognition. In 2025, Humber leaders presented its outcomes at the 25th International Conference on Integrated Care in Lisbon, Portugal, highlighting the program as a model for global adoption.
Looking Ahead
Together, HEART@Home and Hospice@Home demonstrate Humber’s commitment to reimagining how care is delivered, anchored in the belief that integrated care and strong partnerships are essential to meeting patient needs. By working hand-in-hand with Ontario Health Team partners, community agencies, and caregivers, these programs ensure that patients receive seamless, coordinated support during some of the most critical moments of their lives. Both initiatives address clinical needs, in addition to the social determinants of health that shape quality of life.
“Humber’s vision is to transform health care delivery across the continuum,” says Beatrise. “By working with our Ontario Health Team and community partners, we are showing what is possible when we put patients and families at the centre.”
From enabling independence after hospitalization to ensuring dignity at the end of life, Humber’s programs are lighting new ways in health care for the seniors of Northwestern Toronto. These initiatives exemplify integrated and innovative models of care, ensuring the right care, in the right place, at the right time, and offer models that can inspire health systems across Ontario and beyond.