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Ensuring exceptional and safe care in hospital and @ home

Niagara Health and SE Health are collaborating in an innovative, ‘one team’ partnership, delivering exceptional and safe care in hospital and at home to patients in their Niagara Health @ Home Transit

For Peggy Weatherall, there’s no place like home.  Curling up in the comfort of her favourite, green afghan that she hand-knit years ago, admiring the painting of her wedding portrait on the wall in the living room and savouring the smell of perfectly cooked toast coming from her kitchen – even though she finished breakfast hours ago.  Home means so much.

Peggy is a longtime resident of the Niagara region and was once an avid Sudoku player.  She also managed payroll in the Royal Navy in the late 1940s, before coming to Canada.  As a 92-year-old with dementia, that feeling of being in a familiar place and surrounded by the things and people she knows and loves – nothing compares.


No one knows that feeling better than Bob Weatherall, 93, Peggy’s husband for over 70 years and her primary caregiver. “It’s been very hard for me,” admits the kind and soft-spoken, retired Royal Navy officer – also a trained electrical engineer. “Then, when Peggy fell and broke her wrist in March, it was even more difficult.  But having an amazing team, caring for my wife and for me is wonderful.  I can’t thank them enough and I am so happy to have her home.”

Earlier this year, Peggy was part of the Niagara Health@Home Transitions Program – an exemplary ‘one team’ partnership between Niagara Health, a multi-site hospital with a growing network of virtual and community-based services, and SE Health, one of Canada’s largest health care providers, caring for people in their homes and communities for over a century.

The Program, funded by the Ontario Ministry of Health as part of its September 2019 announcement – to expand home and community care, to end hallway health care and to build more capacity in communities across Ontario – strengthens patients’ connections to the hospital and home care providers and delivers 24/7 care and support to patients, for up to 16 weeks, in the places they call home.  Through the creation of personalized, post-discharge, holistic plans of care, the Program decreases the amount of time patients spend in hospital and ensures their safe transition from hospital to home.  These care plans also promote assistance beyond medical care and may include help with social connections, meals and housing.

The interdisciplinary care team includes nurses, personal support workers, physiotherapists, social workers and registered dietitians, to name a few. The emphasis on home care ensures that acute care hospital beds are available for patients who need them most.


“This program is an outstanding example of the innovation taking place at Niagara Health and beyond our walls to ensure patients get the best possible care in the most appropriate setting. Providing consistent and coordinated care in the hospital and at home will help to improve patient flow, provide safe discharges, and better connect patients with services in the community,” said Derek McNally, Executive Vice-President Clinical Services and Chief Nursing Executive at Niagara Health. “We’re proud to be leaders in the shift to community-based care – working with our partners, including SE Health, to deliver extraordinary care to patients and families in Niagara.”

“This innovative model is reinventing how we deliver authentic patient and family-centred care,” said Nancy Lefebre, Chief Clinical Executive and Senior Vice President of Knowledge and Practice at SE Health.  “Using an interdisciplinary care approach, we are enhancing trust between patients, families and caregivers, while offering a seamless transition from hospital to home. We are thrilled to be collaborating with Niagara Health, allowing us to deliver home care services that are providing tremendous support for our patients, families and caregivers and optimizing independence for our patients.  We look forward to building on this partnership and nurturing other transition program partnerships – with hospitals across Ontario – to continue delivering exceptional, personalized care at home.”

The Program began in St. Catharines in November 2019 and has since expanded to Niagara Health’s Welland and Greater Niagara General sites.  The overall goals:  safe and timely transitions and helping people stay at home; better self-care management for patients; and reducing the need for Emergency Department visits or readmission to hospital. The Program has helped close to 150 patients, like Peggy, transition safely from hospital to home and the feedback is amazing.

“Every day, I looked forward to them coming into our home,” said Bob Weatherall, with a big smile.  “They are so friendly and they make sure Peggy is cared for in every way. I couldn’t have gotten through without them. They also freed up a hospital bed doing this,” he added.  “It’s just Peggy and I at home and this wonderful team created a different atmosphere when they were here – you have to experience this level of care for yourself.”

“In my 35 years of nursing, I can say with confidence that this is an outstanding team who gives everything to put patients first, at all times,” said Colleen Monteith, SE Health Transitions Program Care Lead, Niagara Health@Home. “It’s an extremely well-rounded program with numerous benefits to the patients.  We also provide excellence in health teaching to the patient and their family or caregiver.  If, at any time, they have a health issue, they don’t go back through the Emergency Department, we are always here to help – there is exceptional continuity in care.”

“This is one of my favourite life experiences,” said Katharene Gill, SE Health PSW Team Lead, Niagara Health@Home.  “We always work as a team and anytime something comes up we mobilize the resources that are needed.  “Julie K, our SE Health Physiotherapy Assistant, worked wonders with Peggy.  Bob said he has never seen Peggy get up and want to do exercises the way she did with Julie.”


Although Peggy Weatherall had some health challenges, she completed the 16-week program with safe and exceptional care, and a “special team of new friends.”

“On behalf of Peggy and myself, I would like to express my profound gratitude to everybody in this program, for their devotion, professionalism, patience and above all, their sincere friendship in our time of need,” exclaimed Bob Weatherall.  “You’ve taken a tremendous load off my shoulder and we will miss you; you will stay in our hearts forever.”


Please visit Hospital News for the full article.