This article was first published in our 2024-2025 annual report.
In late 2024, Circle of Care partnered with Sinai Health to launch the Sinai Health to Home program. A part of Ontario Health’s broader strategy to improve transitional care, this game-changing initiative supports patients who are identified as being better suited to recover at home rather than remaining in hospital.
Referred directly from Sinai Health’s Hennick Bridgepoint, Mount Sinai Hospital, and the Reactivation Care Centre, patients receive short-term, goal-driven support from Circle of Care’s interprofessional team of home care specialists. This includes Nursing, Social Work, Occupational and Physiotherapy, Personal Support, and Community Services for those facing food, income, or housing challenges. Care plans are created in partnership with patients, families, hospital teams, and primary care providers to ensure continuity and safety.
“I was so happy to be able to come home after a three month stay in the hospital because I could be near my children and continue recovering in a familiar environment. The program team helped a lot. They really understood my situation, mobility issues, and gave me the right treatment and training.”
– Sinai Health to Home patient
“There were two nurses who came to see me; I felt very important being seen by so many people. I felt very rested and relaxed—I can call them on the phone to ask them any questions. The transition home has been excellent.”
– Sinai Health to Home patient
The program enhances individual health outcomes while freeing up resources for other patients who require a hospital environment. Grounded in integrated and responsive service delivery, the model marks a purposeful departure from traditional, fragmented discharge processes.
Sinai Health to Home works because the teams have created a fully integrated system across hospital, community, and home care. This integration allows them to remain agile—checking in constantly with one another and with patients to stay on top of needs as they arise. Regular touchpoints and follow-ups with patients help the teams understand how individuals are doing at home and make timely adjustments to care. It is this combination of integration and responsiveness that enables the program to continuously improve the patient experience. The strength of Sinai Health to Home lies in its ability to shift and adapt while keeping a finger on the pulse. From the program’s launch in November 2024 to October 31, 2025, it has supported nearly 200 patients in transitioning home safely.
“This program is amazing because I can work with patients in their homes—at the right frequency and duration. Here, I have enough time to see real progress. It is incredibly rewarding to develop strong relationships with patients in their own environment, where they are more receptive and engaged. I truly feel like I am making a difference.”
– James B., Physical Therapist, with SH2H team at Circle of Care
This program is a powerful example of what is possible when home and community care organizations build strong, trusting relationships with hospitals—creating a true continuum of care. Together, we are helping people recover safely at home, easing pressure on hospitals by opening up beds, and contributing to a more sustainable, responsive healthcare system.
