For many patients, going home is one of the most important milestones in their recovery. 

But getting home safely can sometimes take more than a discharge plan. A patient may be medically ready to leave hospital but still need help managing their breathing, regaining their strength, taking care of themselves or navigating the next stage of their recovery. 

That’s where Sunnybrook-to-Home comes in. 

Launched in June 2024, the program was created in response to a need identified by Sunnybrook’s clinical teams: finding better ways to support patients who face barriers to safely returning home or staying well once they get there. 

Working closely with community partners, Sunnybrook teams have built a model that brings the right care and supports to patients at home, helping make the transition from hospital more seamless. 

And as respiratory season approaches, the program’s Respiratory Illness Pathway is one example of how Sunnybrook is continuing to adapt to the needs of patients and care teams. 

Bringing Respiratory Care Home 

Recovering from an illness like pneumonia or respiratory syncytial virus (RSV) takes time. Even when a patient is medically stable and ready to leave hospital, they may still ​need respiratory monitoring, oxygen or other supports as they recover. 

The two-week Respiratory Illness Pathway was designed to help bridge that gap. 

Delivered in partnership with SPRINT Senior Care, SE Health and ProResp, the pathway provides short-term support to medically stable patients recovering from an acute respiratory illness. 

Depending on their needs, patients can receive respiratory therapy, nursing, nurse practitioner support, personal support worker services and remote care monitoring, all while continuing their recovery at home. 

For patients requiring oxygen, the pathway provides short-term oxygen therapy and monitoring at home. This helps remove a potential barrier to discharge for patients who are otherwise medically ready to leave hospital. By helping patients transition home sooner, it also frees up critical hospital resources and beds for those who need them most. 

Belinda Wagner is a physiotherapist on the Inpatient General Internal Medicine Unit at Sunnybrook and has utilized this pathway several times. 

“This pathway gives us another option to support patients who are ready to leave hospital but still need some respiratory support as they recover.” She explains, “being able to continue that care at home allows patients to recover in a more comfortable environment while gradually returning to their usual routines. It also means we can better understand how patients are managing with everyday activities in their own home. It’s a win for patients, care teams and hospital capacity, and I’m excited to continue referring appropriate patients to the pathway.” 

A Team Effort That Starts Before Patients Leave Hospital 

Making a successful transition home does not happen in isolation. 

SPRINT Transitional Care Leads work alongside Sunnybrook teams to identify patients’ needs early and connect them with the appropriate health and community services. 

The program has continued to grow since it launched and is now approaching 1,000 patient enrollments. 

Zedrick Laure, Regional Director, Transitional Care at SE Health, describes SB2H as an example of what is possible when hospitals and community providers share a commitment to patient-centred care:  

“SE Health has been a proud partner [in SB2H] since its inception. Together, we have co-designed innovative care pathways that respond to the unique needs of diverse patient populations, helping more people receive seamless, high-quality care in the comfort of their own homes." 

Making the Transition Home Feel a Little Easier 

For patients and families, leaving hospital brings a mixture of relief and uncertainty, but having the right support in place can make that transition feel more manageable. 

L.P., a patient enrolled in the Respiratory Pathway Program, spoke about her experience following her hospitalization for dyspnea. She explains, “I got a lot of support throughout the program, and my transition home was a smooth one. I felt supported while managing my oxygen, dialysis and breathing at home, knowing I still had high-level care and guidance from my care team. The education I received, especially around my ​inhaler and deep breathing exercises, has helped me manage my symptoms and continue recovering comfortably at home.” 

The Respiratory Illness Pathway is also designed to work alongside existing community care. Sunnybrook worked with Ontario Health atHome so patients already receiving its services can access the pathway without disrupting their existing supports. 

Care that Follows Patients Home 

Sunnybrook-to-Home is built around a simple idea: the hospital is just one part of a patient’s recovery. 

By working across hospital and community care, the program lets patients continue their recovery in the place they call home, with the right supports around them. 

As respiratory season approaches, the Respiratory Illness Pathway offers another way for Sunnybrook teams and community partners to help patients get home safely and stay connected to the care they need once they get there. 

Because sometimes, the next step in a patient’s recovery is not another day in hospital. It is home.