Helping more Niagara residents transition safely from hospital to home

Niagara Falls, ON – The Let’s Go Home (LEGHO) program in Niagara has received an additional $125,000 in one-time funding from the Ministry of Health to support clients through March 31, 2026. This investment builds on the program’s $500,000 base funding, helping expand capacity at a time when demand continues to grow.

LEGHO supports eligible older adults (65+) in hospital with a stable, non-emergency health condition and older adults (65+) living with dementia to return home safely after a hospital stay—and, where appropriate, to prevent avoidable hospital admissions—through a six-week bundle of coordinated community supports.

To date this fiscal year, 315 clients qualified for the program. The incremental funding is expected to support at least 50 additional clients.

“An emergency department visit can start at about $3,000 a day,” said Nadia White, Program Manager with Happy in My Home, Community Support Services of Niagara, lead organization for the NOHT-ÉSON initiative. “By comparison, a six-week bundle of services can be a more cost-effective way to help someone recover, regain confidence, and live independently at home.”

LEGHO is delivered through a coordinated network of partners. Niagara Health plays a key role by identifying eligible patients and initiating referrals through hospital discharge planning, while working collaboratively with community partners on process improvements and efficient transitions.

“Our Home First approach guides how we plan care once a patient no longer needs hospital-level services,” said Lisa Hildebrand, Niagara Health’s Director of Access and Flow and Regional Stroke Program.

“Hospitals are not the right place for recovery when care can be safely and appropriately provided at home, where patients are often more comfortable and supported. This investment is timely and important. It helps ensure people receive care in the right setting, at the right time, based on their clinical needs, while allowing hospitals to focus on delivering safe, high-quality care for patients who truly need to be here.”

For individuals living with cognitive impairment, the Alzheimer Society of Niagara Region provides specialized dementia-focused navigation services and caregiver respite for the program’s dementia stream, reflecting its expertise in dementia care.

“People living with dementia do best in familiar surroundings, not in busy hospital settings where symptoms can worsen,” said Teena Kindt, CEO of the Alzheimer Society of Niagara Region.

“Supporting individuals to return home quickly and safely helps preserve their independence and reduces unnecessary stress. Through LEGHO, families are connected to our dementia specialized services much earlier, and care partners receive in‑home respite to ensure no one is navigating this journey alone.”

In addition, the program’s community delivery model leverages partnerships with Meals on Wheels agencies across Niagara to support food security for clients, and brokered supports through home maintenance/repair services that can assist in complex situations such as hoarding-related safety concerns.

Program staff report that funding comes at an optimal time, as referrals are increasing due to cold and flu season.

“We’re seeing referrals come in quickly,” said Cherie Della-Gatta, LEGHO Supervisor. “This funding bump will be beneficial to many people, and our team has put strategies in place to ensure we can respond and support as many individuals as possible.”

As the program has matured, partners have refined service design to better match local needs—through the introduction of Safety at Home assessments to reduce fall risk and promote safe living environments.

LEGHO is designed to be flexible and client-led. The six-week bundle includes a minimum of three services, and clients may choose which supports best meet their needs (for example, Meals on Wheels, homemaking, transportation, respite and/or safety recommendations).

The program also supports caregivers by helping families understand available community services and navigate options beyond the initial six-week period.

“Even though it’s a six-week bundle, we often see people stay connected to supports long-term because families learn what’s available and how to access it,” said Della-Gatta.