Hospital Discharge Planning

Hospital discharge can happen faster than families expect and feel faster than the person being discharged is ready for. Hospitals face real pressure on bed availability, and discharge decisions are sometimes made before the family has had time to arrange adequate support at home.

The period immediately after discharge is one of the highest-risk periods for older adults. Research consistently shows that readmission rates in the weeks following discharge are significant, and that many of these readmissions are preventable with better preparation and support during the transition.

The good news is that most of the risks are known and addressable. The key is knowing what they are and planning for them before the person leaves the hospital, not after.

Before discharge happens

As soon as a hospital admission occurs, begin thinking about discharge. Ask the hospital team who is responsible for discharge planning and make contact with that person early. In most hospitals this is a social worker, a discharge planner, or a case manager.

Ask directly: what does this person need to be able to go home safely? What will they be able to do and not do in the first days and weeks after discharge? What follow-up care will be required?

Do not wait to be told. Ask.

Understand what is being discharged to

Discharge home requires that the home is set up to receive the person safely. Discharge to a rehabilitation facility, a long-term care facility, or a transition care bed requires understanding what each of these options involves and what the plan is from there.

If discharge home is the plan, the questions to ask are: Can this person manage safely at home with the current level of support? What additional support is needed and can it be arranged before discharge?

• Medication changes: Medications are frequently added, removed, or adjusted during a hospital stay. Understanding what has changed and why, and ensuring the person can manage the new regimen correctly at home, is one of the most important discharge tasks.
• Premature discharge: People are sometimes discharged before they are truly ready because of bed pressures. Knowing your right to raise concerns about premature discharge and how to do so matters.
• Falls during recovery: Physical deconditioning during a hospital stay increases fall risk during recovery. The home environment needs to be assessed with this in mind.
• Infection and wound care: If the hospitalization involved surgery or infection, wound care instructions need to be clearly understood and followed. Infection after discharge is a common cause of readmission.
• Follow-up appointment gaps: The period between discharge and the first follow-up appointment is a gap where problems can develop undetected. Knowing when the first appointment is and how to reach someone if problems arise before then is important.
• Caregiver unpreparedness: Family members who take on caregiving responsibilities after discharge are often not given adequate information or training. Ask for what you need to know.

Home care after discharge

In-home support after discharge may include nursing visits for wound care or medication management, physiotherapy or occupational therapy to support recovery, and personal support workers to help with daily activities during the recovery period. Some of this may be arranged through the hospital; some may need to be arranged independently.

Find vetted home care providers in the directory.

Rehabilitation

For many older adults after a significant hospitalization, particularly following a fall, a fracture, a stroke, or surgery, a period of rehabilitation is an important part of recovery. This may happen in a dedicated rehabilitation facility, in a long-term care facility with a rehabilitation program, or at home through visiting therapists. Understanding what the options are and which is most appropriate is worth discussing with the hospital team.

Home modifications for the recovery period

Even a temporary recovery period may require temporary changes to the home: a hospital bed on the main floor, a commode, grab bars, or equipment to assist with bathing and mobility. Knowing what equipment is needed before discharge, and having it in place before the person arrives home, prevents problems.

Find vetted mobility and equipment providers in the directory.

Medication management

If managing multiple medications at home is a concern, a pharmacist can provide a medication review and packaging in blister packs or other formats that make taking the right medications at the right times easier. Some home care programs include medication support.

Transportation for follow-up appointments

The person being discharged will need to get to follow-up appointments during a period when they may not be able to drive. Arranging this before discharge is better than scrambling afterward.

Find vetted transportation services in the directory.

Most health systems include some level of funded transition support after hospitalization. This may include nursing visits, therapy, and personal support during the recovery period. The amount of support, how it is accessed, and how long it lasts varies significantly by location.

Ask the hospital discharge planner or social worker explicitly what funded supports are available in your area and how to access them. Do not assume that support will be automatically arranged.

Check the directory under your province or region for transition care and home support services.

• Some post-discharge home care and rehabilitation may be publicly funded; the amount and eligibility criteria vary by location
• Equipment needed for the recovery period may be available through loan programs; ask the hospital occupational therapist or social worker
• Private home care can be arranged to supplement publicly funded support if needed
• Transportation to follow-up appointments may be covered by insurance or community programs for eligible individuals

Get clarity on what is funded and what is not as early as possible so that private arrangements can be made in time if needed.

Before discharge, for the hospital team

• What exactly happened and what does recovery look like?
• What can and cannot this person do when they go home?
• What medications have changed and why? Can someone go through each one with us?
• What home support has been arranged and what do we need to arrange ourselves?
• What signs should we watch for that would mean coming back to the emergency room?
• When is the first follow-up appointment and with whom?
• Who do we call if we have questions or concerns after we get home?

For the home care provider after discharge

• What exactly are you providing and how often?
• What are you not providing that we need to arrange separately?
• How do we reach someone if there is a problem between visits?
• What should we watch for and report to you?

A discharge checklist that covers medications, follow-up appointments, home care arrangements, equipment, and warning signs to watch for helps ensure nothing is missed in what is often a rushed transition.

A medication list with the current complete list of medications including what each is for, the correct dose, and the schedule is essential for the person, the caregiver, and any home care providers.

An emergency contact list including the family doctor, the specialist seen in hospital, the home care provider, and after-hours contact numbers should be posted somewhere visible at home.

Downloadable resources will be added to this section as the site develops.

• Home Care providers for nursing, therapy, and personal support after discharge
• Mobility and Equipment providers for recovery equipment
• Transportation services for follow-up appointments
• Medical Alert and Safety providers if a device is now indicated

1. As soon as a hospital admission happens, ask to speak with the discharge planner or social worker. Start planning before discharge is imminent.
2. Get clear answers about what the person can and cannot do at home and what support is needed before they leave the hospital.
3. Get a complete medication list with explanations before leaving the hospital. Have someone go through every change with you.
4. Confirm what funded home support has been arranged and what you need to arrange privately. Do not assume.
5. Make sure the home is ready before the person arrives: any equipment needed should be in place, hazards addressed, and the environment set up for the recovery period.
6. Know the warning signs that would mean returning to the emergency room and write them down.
7. Confirm the first follow-up appointment before leaving the hospital and arrange transportation for it.