Hamilton Health Sciences’ (HHS) Hospital 2 Home team consists of regulated health professionals who partner with patients to develop coordinated care plans based on what is most important to the patient, and what is most concerning to the patient about their health. The Hospital 2 Home team utilizes Ontario’s Health Links Model of Care to guide practice along with Health Quality Ontario’s Coordinated Care Planning Tool (CCP) to identify patient specific goals, and to partner with health care, social and community services providers to help patients achieve their goals. HHS’ Hospital 2 Home team views patients through a trauma informed care lens and utilizes motivational interviewing skills to develop true partnerships with patients – care plan development starts with asking patients open ended questions such as “What is most important to you right now?” Patients are supported to develop the knowledge and skills required to be successful, such as self-management of chronic conditions. Standardized Readiness Assessments are used if patients are willing to talk about various issues, and a non-judgmental curiosity is applied throughout the development and implementation of the care planning process. HHS’ Hospital 2 Home team truly views the patient as a partner and respects the expertise they have related to their health and social needs.

← Back to Search Results

Leading Practices are submitted by health organizations from around the world. The contents of the Leading Practices library do not reflect opinions or views of HSO or its affiliates. If you have questions, concerns or suggestions please email us at leadingpractices@healthstandards.org