Provides a free bundle of services to eligible seniors, who due to lack of resources or appropriate supports, require assistance in returning home after a hospital stay.  Bundled services include:
transportation home from hospital and rides to up to 2 follow up medical appointments: 4 days of frozen meals; home management (essential laundry, tidy up, grocery shopping, meal prep); referrals and connections to other programs and agencies who can aid in the client's recovery; and companionship.  

Eligibility Criteria - Client must (all must be met):

• aged 55+
• have a planned or recent discharge from hospital to any home setting in their community
• require transition and re-settlement support for between 4-6 weeks
• be medically stable and safe for discharge
• be willing to accept services
• client (at least one must be met):
• has been identified as at risk for re-admission to hospital or ED visit post-discharge by hospital/multidisciplinary team
• has needs which exceed what family/care partners can provide
• has limited support available from family/support network or lives alone