Going Home

The Discharge Planning process often begins shortly after you enter the hospital with an initial assessment of your previous level of functioning, home setup, and social supports. This assessment is referred to as a psychosocial assessment and helps inform the Hospital’s interdisciplinary team about your specific care needs.

With your needs in the mind, the hospital team will meet with you and your decision makers to discuss the next transition and to create a Discharge Plan. This process is designed to support you and answer key questions such as:

• Where will I go?
• Who will help me?
• What equipment will I need?
  

When a discharge date and destination are determined, the interdisciplinary team will complete any appropriate referrals such as to Home and Community Care (formerly known as the Community Care Access Centre). The team can provide information to assist you and your family to arrange for other necessary equipment and support.

When you are preparing to go home from hospital, some pertinent questions to ask include:

• What treatment you received
• Whether you will have to pick up a prescription before you go home
• What medicine you must take, how to take it, and any side effects
• What symptoms to watch for and who to call if something does not feel right
• What foods you should eat and not eat
• When you can go back to normal activities, such as work, school, exercise, and driving
• What follow-up appointments you will need and who will make them
• What home care support do you need, when it will start, and who to contact

Discharge transportation costs are the patient’s responsibility. The interdisciplinary team can suggest transportation options as required.

Home First is an approach that helps eligible hospital patients to continue their recovery safely at home while receiving enhanced home-care services for up to 60 days. These patients are often frail seniors who have completed their acute care treatment. Your health care team and the hospital-based Home and Community Care Coordinator (formerly CCAC) will co-ordinate any service required to ensure a safe discharge home.

What are the main benefits for patients and families?

• Patients can recuperate in a familiar environment, reducing the risk of losing strength from lack of mobility while remaining in hospital. There is no cost for eligible services provided through Home and Community Care.
• Seniors have more time to improve their health status prior to making a major decision about their future care needs.

What are the main benefits for the health system?

• Home First helps people get better at home and relieve pressure on hospitals.
• Preventing premature admission to long-term care homes results in greater access to these beds for individuals who require a more intensive level of care.
• When appropriately managed, care in the home can moderate the demand for more costly health-care options while maintaining a person’s independence.

Home and Community Care is coordinated through the Champlain Local Health Integration Network (LHIN). It connects you with the care you need at home and in your community by offering information, referral and access to services to help you maintain health, independence and quality of life. Services are available for people of all ages.

For general Champlain Home and Community Care inquiries, or to make a referral, contact us toll free at:

310-2222 (no area code required)

Toll-Free: 1-800-538-0520

Outside Canada: 613-745-5525

For more information please visit Home and Community Care.  

Additional Home and Community Care support can be found by visiting Champlain Healthline.