our practice - oriented question was  how can the community sector work with their local hospitals to smooth the patient 's transition home from hospital. our answer was home at last , an innovative hospital - community collaboration in the greater toronto , ontario , canada . to ensure that when seniors have had a hospital stay or emergency department visit , they are discharged in a timely manner and transitioned back to the community quickly with the right supports . the hospital changes its discharge processes to achieve a pre - determined discharge time , usually 11:00 am , at which time transportation arrives along with a community worker who rides home with the patient and then stays to get them settled until a family member arrives home or 9:00 pm at the latest . the worker can pick up groceries and prescriptions if necessary , prepare small meals , perform light housekeeping , do laundry , and provide toileting assistance . the home at last care coordinator follows - up with the patient the next day , and designs and arranges a package of community services and follow - up visits . the program has enabled participating hospitals to achieve expected discharge time for patients ; increase patient satisfaction with the discharge process and greater compliance with discharge plan orders . in addition , patient throughput has been improved by at least 6 hours and social readmissions have decreased .
introductionour practice - oriented question was  how can the community sector work with their local hospitals to smooth the patient 's transition home from hospital. our answer was home at last , an innovative hospital - community collaboration in the greater toronto , ontario , canada.objectiveto ensure that when seniors have had a hospital stay or emergency department visit , they are discharged in a timely manner and transitioned back to the community quickly with the right supports.the programthe hospital changes its discharge processes to achieve a pre - determined discharge time , usually 11:00 am , at which time transportation arrives along with a community worker who rides home with the patient and then stays to get them settled until a family member arrives home or 9:00 pm at the latest . 
 the worker can pick up groceries and prescriptions if necessary , prepare small meals , perform light housekeeping , do laundry , and provide toileting assistance . 
 the home at last care coordinator follows - up with the patient the next day , and designs and arranges a package of community services and follow - up visits.resultsthe program has enabled participating hospitals to achieve expected discharge time for patients ; increase patient satisfaction with the discharge process and greater compliance with discharge plan orders . in addition , patient throughput has been improved by at least 6 hours and social readmissions have decreased .