Nearly 19 months after launching GGH@Home and the Remote Care Monitoring Program, Guelph General Hospital (GGH) is expanding both programs to help more patients with complex health needs transition safely from hospital to home and remain supported in the community.
From March 2025 to August 2026, the Hospital-to-Home program admitted 401 patients. Among the patients who had completed the program as of August 31, 2026, over 70 per cent (281 patients) were discharged to self-care which is the ideal outcome. Building on that progress, GGH has added new Hospital-to-Home services, increased coordination, and welcomed additional roles to the team.
The expanded service model, delivered through GGH@Home in partnership with Bayshore Integrated Care Solutions, includes new respiratory and mental health care plans. The respiratory care plan provides up to 14 days of respiratory therapy, nursing support, oxygen management, remote monitoring, patient education, and coordinated transition planning for eligible patients following discharge. The mental health care plan provides multidisciplinary support for up to a 16-week period, helping connect patients with nursing, social work, psychotherapy, addictions counselling, rehabilitation, and community reintegration services based on their needs.
To help eligible patients access services sooner, GGH has also introduced a second Hospital-to-Home navigator, focused on supporting patients in the Emergency Department. Working closely with the Emergency Department team, the navigator identifies patients who may be safely supported in the community and facilitates timely connections to appropriate services and resources.
The addition of this role will also increase GGH's capacity to manage a growing volume of inpatient referrals.
With the team expanding from one to two navigators, patients and families will receive enhanced support in understanding their care plans, coordinating services, and transitioning safely from hospital to home.
“These programs are showing what is possible when hospital and community partners organize care around the patient,” said Marisa Vaglica, Vice President, Patient Services and Chief Nursing Executive at GGH. “By expanding our care pathways, coordination and navigation supports, we can help more patients return home safely and ensure hospital beds are available for those who need acute care.”
“People with complex health and social needs often face barriers when moving between hospital and community care. Strengthening partnerships across health and community services helps remove those barriers and ensures people can access the right supports at the right time. By working together, we can create more coordinated pathways that help people stabilize and recover in their own communities,” said Melissa Kwiatkowski, CEO at Guelph Community Health Center.
“The expanded Hospital-to-Home services build on our shared commitment to timely, coordinated care after discharge,” said Emmi Perkins, Director of Transformation at the Guelph Wellington Ontario Health Team. “We look forward to continuing our work with our community partners as the program grows to meet a broader range of patient needs.”
The Remote Care Monitoring Program will continue to complement GGH@Home by using tools such as fall notifications, medication dispensing devices, and in-home passive monitoring sensors, supported by proactive wellness checks and personalized follow-up. Together, the programs address both health needs and the social factors that can affect a person’s ability to recover and live independently at home.
These improvements help more patients get the care they need, reduce unnecessary hospital visits, and support a safe recovery in the comforts of home. GGH remains committed to working with community partners to make care easier to access and better connected for residents in Guelph-Wellington.
Key Facts
- The GGH@Home Program launched in February 2025 and the Remote Home Monitoring Program launched in March 2025
- 58 patients supported through Remote Care Monitoring
- 401 patients admitted to the Hospital-to-Home program from March 2025 to August 2026
- Over 70 per cent of patients who had completed the program were discharged to self-care
- GGH cared for 1,105 patients with respiratory-related conditions in FY25/26, with average hospital stays rising by 4.5% compared to the previous year
- 447 Emergency Department visits by supportive-housing residents in 2025–26, up 33.4 per cent from the previous year
- It is estimated that 180 to 360 additional Hospital-to-Home referrals will occur annually across the new and existing care options