If you are eligible, your Brockville@Home coordinator will meet with you, your care partners, and your hospital team to identify your rehabilitation goals, and develop your personalized care plan.
This care plan will be shared with everyone involved in your home care.

Before discharge, you will receive:

• A copy of your completed care plan (from SE Health), including your first scheduled home visit appointment and the name of the team member who will visit you. 
• Brockville@Home brochure, including contact information for questions and concerns. 
• Pamphlets and/or information regarding any other referrals sent on your behalf.

On the day of discharge, a member of the Brockville@Home team will call to confirm you arrived home safely.

Your Brockville@Home team will:

• Visit you within 24 hours.
• Check in daily for the first 7 days.
• After the first week, work with you to determine appropriate check‑in frequency.
• Collaborate closely with the hospital to ensure your goals continue to be met.
• Keep your Primary Care Provider updated.
• Use a mix of:
• In‑home visits.
• Phone calls.
• Technology (e.g., virtual visits or telemonitoring).
• Connect you with community programs such as:
• Senior Support Services which include services such as Meals on Wheels and transportation supports.
• Caregiver support resources.
• Paramedicine.
• Other community programs as required.

Your care plan is flexible: if your care needs change, the plan will be adjusted accordingly.

A 24/7 support line is available for clinical questions or concerns, 1-855-844-5181.

Brockville@Home offers two program durations depending on clinical need:

• 8-week program
• 16-week program (standard bundled care pathway) 

Brockville General’s contracted bundled care model with SE Health is typically a 16‑week pathway, however a shorter 8‑week bundle options is available for appropriate patients.

If your condition requires readmission to hospital, the Brockville@Home team stays informed and will re-assess with the goal to resume services when you transition back home.

If additional care is needed after your 16‑week program:

• The Brockville@Home team will maintain ongoing communication, monitor your progress, and adjust services based on your needs. 
• At the program's midpoint, the team will contact you for feedback and begin planning future supports.
• You can reach out to the Brockville@Home team at any time - no need to wait for us to contact you if you have questions or concerns. 
• If required, we will help you reconnect with Ontario Health atHome approximately one month before program completion to arrange long-term or transitional home care services. 

You cannot receive Ontario Health atHome (OHaH) services while participating in the Brockville@Home program. OHaH will be advised of your participation with the Brockville@Home program and close your file.

Please note, if you have a Long Term Care (LTC) application completed, you can continue connecting with your OHaH community coordinator regarding this. There will be no impact or change to your LTC application because of your participation with Brockville@Home.

Upon completion of the Brockville@Home program, if OHaH services are required, assistance will be provided to re-establish them; however, continuity of the same support staff cannot be guaranteed.