This year, the North York Community Access to Resources Enabling Support (NYCARES) program celebrates five years of helping North York General (NYG) patients with complex care needs recover safely in the comfort of their own homes. Since launching in 2021, the program has supported patients and their families with personalized, coordinated care that bridges the gap between hospital and home while reducing pressure on Ontario's health care system. 

For many people recovering in hospital, home is where they want to be. It is where they feel most comfortable, surrounded by family, familiar routines and the comforts that support healing. But for patients with complex medical needs, returning home often requires specialized care and coordinated support. 

Created by North York Toronto Health Partners Ontario Health Team (NYTHP OHT) with a number of community partners including VHA Home HealthCare (VHA), NYCARES was designed to help patients with complex care and medium intensity rehab transition safely from NYG to home. Rather than remaining in hospital, eligible patients receive up to 90 days of intensive, personalized care at home before transitioning to ongoing home care support or a long-term care facility, depending on their individual needs. 

"The program is designed for some of the most complex patients in the community who couldn't otherwise be supported through traditional home care services and would likely remain in a hospital bed while waiting for their next care destination," explains Jasveen Kaur, VHA Supervisor, Integrated Service Delivery Systems. "Working closely with hospital partners, our team brings patients home and provides a comprehensive mix of services based on each person's unique needs. We support not only the patient, but also their family, helping everyone feel confident throughout the transition." 

Built on an integrated care model, NYCARES brings together a connected team of health care professionals to provide coordinated, people-centred care that wraps services around each patient and their family. The goal is simple: deliver the right care, at the right time, in the place people most want to be. 

Every patient's journey is different, which is why each care plan is personalized. Depending on their needs, patients may receive personal support, nursing, occupational therapy, physiotherapy, speech-language pathology, dietetic services, pharmacy support, primary care and connections to community services. This collaborative approach helps patients regain strength, improve independence, and continue their recovery in a familiar environment. 

"Every patient referred to NYCARES has their own unique story, needs and circumstances,” says Elmira Nobakht, Integrated Transitions Coordinator at NYG. “Thoughtful coordination and strong partnerships between hospital and community teams can make a real difference, helping patients and families navigate complex transitions and return home safely with the support they need.” 

Over the past five years, the program has continued to evolve to meet the growing needs of the community. Today, the program supports nearly twice as many patients as it did when first launched. Additional care pathways, including complex rehabilitation services and enhanced community supports such as VHA's Restored Homes: Extreme Clean program, have expanded the range of care available to patients recovering at home. 

Most importantly, the success of the program is measured in the lives it has touched. 

"The care that my dad received from NYCARES showed us what compassionate, coordinated care can look like,” shared one family caregiver. "I don't know what we would have done without the team." 

For many families, recovering at home can feel overwhelming at first. Having an experienced, compassionate team guiding them through every step helps ease that uncertainty, providing reassurance that they are not facing the journey alone. 

At the end of the 90-day program, approximately 20 per cent of patients are able to transition to self-care, 40 per cent of patients receive ongoing home care support, and 40 per cent of patients move into a long-term care facility based on their evolving needs. One of the program's most meaningful outcomes is that some patients who were originally expected to enter long-term care can remain safely at home. 

"With the intensive support we provide, many patients become more stable, and caregivers feel more confident caring for their loved one at home," says Kaur. "In some cases, families decide they no longer need long-term care because they've seen what's possible with the right supports in place." 

As NYCARES marks its fifth anniversary, it continues to demonstrate what is possible when hospitals, home care providers and community organizations work together around the needs of patients. By helping more people recover safely at home, the program is improving patient experiences, supporting caregivers and ensuring more Ontarians can receive the best care tailored for their individual needs. ​