Abstract

Launched in June 2024, the Sunnybrook-to-Home (SB2H) program was designed to support older adults' transitions from hospital to home through the integration of hospital, home care and community services. Between June 2024 and December 2025, 593 unique patients were enrolled, with approximately 33% referred from the emergency department. Patients who enrolled in SB2H experienced faster access to home care (average 1 day vs. a Toronto Central regional average of 5 days) and shorter alternate level of care stays (3.7 days compared with 7.5 days among non-SB2H patients). Integration of community services was associated with linkage of approximately 20% of patients to essential social supports, including Meals on Wheels and emergency food baskets. This article reflects on key learnings from the SB2H program, with particular attention to the value of embedded community partnerships, the role of social and navigation supports and the importance of co-creating transitional care models with front-line teams.