Please keep in mind that while it’s useful to have an overview of how the Ontario health care system works, your circumstances are unique to you. There is no one size fits all elder care solution.
For the sake of simplicity we’ve used the term “client” to describe the elderly individual who is returning home. The term “client” has replaced “patient” at many hospitals.
Also, we have numbered and named the steps in the discharge process. In reality no-one actually refers to the steps as separate steps, they are all one process.
The Registered Nurse assessment difference is real
Lisa’s assessment skills meant my mother got the right kind of care. It was a big relief to know that mom would be safe and well cared for in her own home.
~ Ms. Junkin, Client’s daughter
Step 1 – Notification of Discharge:
Usually the hospital will notify the family that they plan on discharging the client. Notice can be as short as one day or as long as a week in advance of the discharge date.
Step 2 – Needs Assessment:
The hospital Discharge Planner (or, in some cases Social Worker) will help the family identify the arrangements that need to be made in order for the discharge to be successful. The Discharge Planner is not responsible for actually making the arrangements, although they will, on occasion, assist in making some of them.
Step 3 – Coordination:
Generally the family is responsible for coordinating all the various services that may need to be put in place, booking follow up doctors appointments and arranging all the household details – making sure food is in the refrigerator, medications are up to date, old prescriptions have been removed from the household, the household environment is safe (with the limitations that the client now has), etc.
Step 4 – CCAC/LHIN evaluation:
Hospitals have a LHIN (Local Health Integration Network) coordinator on-site who determines the number of “home care” hours of care the client is eligible for under the government program. Note: LHINs were previously known as CCAC (Community Care Access Centre) /LHINs website
Note: If you feel your parent needs more care than the CCAC is able to provide, call Eldercare Home Health at:
Our Registered Nurse Case Managers can arrange for the additional PSW care your parent needs, complimenting the care that the CCAC is able to provide. We’ll help make sure your parent is safe and well cared for.
Step 5 – Transfer home:
The family may make arrangements to transfer the client home themselves or, if required they can book a transfer ambulance through the hospital.
In an ideal world, all services would be in place and all details have been sorted out prior to the client’s arrival home. In reality, this seldom happens. It is not unusual, for example for clients to return home without their medication, without a new prescription, without an exercise schedule, wheelchair etc.
Step 6 – Homecare: Community Care Access Centre (CCAC) / Local Health Integration Networks (LHINs) visits:
For most people it is comforting to have a consistent caregiver.
Unfortunately, due to a variety of factors, it is very difficult for CCAC/LHIN contracted agencies to provide consistent caregivers for clients.
(A note here regarding CCAC/LHIN caregivers. CCAC/LHIN contracts independent companies to provide caregivers on its behalf. The CCAC/LHIN itself does not employ caregivers).
Eldercare Home Health is not aCCAC/LHIN care provider, although we are fortunate to have a very good relationship with many of theCCAC/LHIN offices. At Eldercare Home Health we are accountable directly to you and there is always someone to talk to if you have any questions regarding any aspect of the care we provide.
Step 7 – Ongoing supervision of care and health:
There are many considerations for a successful return home. Having the right care in place is key, but there are other factors that can also make a significant difference to the health of clients: maintaining a clean environment, nutritional considerations, mental stimulus, socialization, exercise regimen, monitoring changes in health status, communication between health professionals and family members, coordination of services etc.
Step 8. Awareness of change in condition:
It is important that the client’s condition is monitored and that a knowledgeable care professional take appropriate action when health changes occur.
At Eldercare Home Health taking care of the elderly is all we do
We know how the Ontario healthcare system works, what services our clients are entitled to receive throughCCAC/LHIN and how to access them. We advocate for the well-being of our clients and coordinate and monitor all delivery of services, from equipment to home blood work, medication administration and personal care. Want to learn more? Contact us now.