St. Joseph’s Home Care (St. Joe’s Home Care)
Integrating Clinical and Social Care for Complex Needs at Home

Many individuals today prefer to remain at home as their health and social needs become more complex, requiring support that extends beyond clinical care.

St. Joseph’s Home Care (St. Joe’s Home Care) supports them through integrated home and community-based care. With a whole-person approach, it integrates clinical care with housing, mental health and substance use support to address the full scope of complex and evolving care needs.

Every individual at St. Joe’s Home Care is guided by the legacy of the Sisters of St. Joseph to bring hope and healing to people who may not have access to care.

“From clinical teams to supervisors to recruiters, everyone at St. Joseph’s Home Care is grounded in a shared purpose to serve individuals in the community who need care,” says Nadia Surani, executive director.

St. Joe’s Home Care is a proud member of St. Joseph’s Health System, one of Canada’s largest and most comprehensive healthcare systems. Its team of over 350 healthcare workers serves approximately 6,000 clients every year across Hamilton, Niagara, Haldimand–Brant, Kitchener–Waterloo and Halton. Its multidisciplinary team, comprising nurses, dieticians and occupational therapists, is equipped to navigate clinical as well as social determinants of health, coordinating services across home settings, supportive housing and community environments.

St. Joe’s Home Care supports seniors who wish to remain at home, individuals requiring nursing or daily personal support and those transitioning from hospital to home. With support ranging from post-surgical rehabilitation and chronic condition management to community reintegration, it helps individuals avoid hospital visits and readmissions.

Addressing Complex Needs with Unstoppable Compassion

At St. Joe’s Home Care, staff listen closely to each individual and tailor clinical, personal support and social services to their needs, rather than applying a standard approach. This includes personal care and daily exercises at home. Clients facing housing instability, mental health concerns and substance use are treated with dignity and receive adequate support as they transition back into the community.

Its transitional care and hospital-to-home programs are designed to deliver proactive, comprehensive and coordinated support. St. Joe’s Home Care’s fifty-bed transitional care unit at First Place in Hamilton combines clinical care with social support to address barriers to recovery.

In one instance, a client was unable to access available community resources due to the lack of an indigenous status card. St. Joe’s Home Care’s team engaged with the individual and their family to identify the root of the issue, with a social worker facilitating the entire process. This intervention unlocked access to essential services, illustrating how targeted, nonclinical support can play a decisive role in recovery and reintegration.

Managing Multifaceted Care Needs

In more complex situations, recovery depends on clinical, behavioral and social factors that extend beyond traditional care, influencing an individual’s ability to transition safely back into the community.

In one instance, a patient who had spent years in an acute mental health setting faced hurdles in securing housing due to behavioral issues coupled with substance use. St. Joe’s Home Care’s multidisciplinary coordination and integrated planning addressed these barriers, enabling a safe transition and a gradual return to independent living.

As patient needs become more complex, St. Joe’s Home Care’s care model evolves with it, addressing the changing realities of the communities. It plans to expand into non-clinical supports that complement existing care services, including addon services like meals, personal care and other essential needs. To better support marginalized and vulnerable individuals, St. Joe’s Home Care is expanding its reach and expertise across the regions it serves.

By going beyond clinical needs to address social and environmental factors that shape recovery, St. Joe’s Home Care helps individuals remain at home, maintain independence and transition safely within their communities.