As one of Canada’s largest acute care hospitals, Humber River Health (Humber) is dedicated to empowering its patients, while providing them with comprehensive, quality care closer to home. In the realm of healthcare, especially at the end of life (EOL), the setting in which one receives care can profoundly impact their experience. Traditional hospital environments often do not provide the support and comfort desired by those in their final days. Time that should be spent surrounded by family and loved ones in a familiar environment, is often disrupted in a busy and institutional hospital setting.
Humber services a densely populated area in Northwest Toronto, a region characterised by a significant elderly population, a high material deprivation index and a higher-than-average number of EOL hospitalizations. In this region, there are 610 deaths per 100,000 residents, where the majority of these deaths occur at Humber. Thus, the excessive strain caused by palliative patients on hospital resources becomes a significant bottleneck in enhancing efficiency. Limited hospice beds and community support have traditionally hindered the ability for many to die at home, despite their wishes, as only 36 per cent of Canadians receive palliative care at home.
Recognizing this critical gap, Humber has pioneered the integrated Hospice @ Home program, a transformational approach to palliative care that emphasizes comfort, dignity, and familial presence by providing a holistic approach to care, right in the patient’s home while addressing financial barriers and health equity concerns.
Transforming end-of-life care
Hospice @ Home assists palliative care patients, most of whom are older adults, through the last year of their lives. With a specialized and dedicated interdisciplinary team, consisting of registered nurses, personal support workers, social workers, spiritual care, and other complementary therapists and volunteers, and access to a 24/7 phone line, the goal is to support these patients and their families at home without compromising the quality and breadth of EOL services they are provided. This pilot program – which launched in January 2024 – goes beyond what is provided through home care services, by integrating hospice and community services that cares for the patient and their caregiver.
Humber is supporting patients who have life-limiting or life-threatening diagnoses, including those with primary palliative diagnosis of cancer or a chronic illness, such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), renal disease, and pulmonary fibrosis, among others.
Patients no longer have to endure long hospital stays and can spend their last weeks surrounded by loved ones. “No price can be attached to the act of allowing a loved one to pass away in the comfort of their own home,” says Kathleen Kirk, Manager of Schulich Family Medicine Teaching Unit and Integrated Care Services at Humber. “Not only does this support their wishes, but from a Hospital perspective, it frees up additional hospital beds for acute care patients, alleviating some of the strain on the healthcare system.”
A collaborative effort
The Hospice @ Home initiative represents a collaboration between Humber, Dorothy Ley Hospice, Home and Community Care Support Services, and Etobicoke Services for Seniors (ESS) Community Support Services provider. To support the reduction of avoidable repeat ED visits, hospital readmissions, and hospital deaths related to palliative care, Humber’s partnership with Dorothy Ley Hospice provides the necessary care coordination, physicians, and psychosocial services required to keep patients in their homes, with their loved ones. They help oversee the program, identify and enroll patients, as well as support the patient transition from a hospital setting back into their homes with the assistance of ESS through a dedicated comfort fund. In addition, the program provides counselling and other psychosocial services to patients and their families early in their palliative journey as an upstream approach to ensure time to plan for EOL in a supportive
environment.
With the support of Women in Kindness (WINK) and Humber, the program has secured the necessary funding to cover various expenses, from medical equipment and supplies, to comfort fund items such as transportation and meals, ensuring no patient is left without the care they deserve.
The impact of Hospice @ Home
Since its launch, Hospice @ Home has made significant strides, supporting the transition of five patients back to their homes. These patients were discharged with an initial care plan, which provided guidance and support for the first few days at home. Once back in their homes, the dedicated teams from Dorothy Ley Hospice and Home and Community Care Support Services evaluated the patient’s and family’s needs, with a care plan that is fluid and changes with the needs of the person. The program’s flexibility allows for care plans that adapt to changing needs, ensuring personalized and comprehensive support.
Looking ahead
The effect of the Hospice @ Home program is multi-dimensional. For patients, it means receiving high-quality palliative care in the comfort and privacy of their own homes, surrounded by loved ones. For families, it provides support and relief during a challenging time, ensuring they are not alone in their caregiving roles. For the healthcare system, it represents a shift towards more integrated, sustainable and patient-centered care models.
The success of the Hospice @ Home pilot project marks the shift towards integrated care and a population health approach in palliative care within our region. With continued support from donors, community partners, and the dedicated team at Humber, the program is poised for scale and spread, bringing hope and comfort to more families. “Ultimately, we want to ensure that patients and their families feel supported and valued by their care providers,” says Beatrise Edelstein, Vice President of Post-Acute Care and Health System Partnerships at Humber. “Our hope is that their wishes are respected and their needs are met within a compassionate and caring way during a very challenging time.”
By sharing the benefits of this program, Humber’s hope is to encourage scale and spread of this integrated model of palliative home care delivery across Ontario. In a society that often shies away from discussions of death and dying, Hospice @ Home demonstrates the importance of facing these realities with compassion, dignity, and respect. It challenges us to reimagine EOL care, not as a series of medical interventions, but as a holistic journey that honours the individual and their loved ones. Through programs like Hospice @ Home, Humber is not just transforming palliative care; it is lighting new ways in healthcare.
By Shahana Gaur
Shahana Gaur Senior is a Writer/Communications Specialist at Humber River Hospital.