How Ontario Health & Home and Community Care Support Services (HCCSS) can help you!
Please keep in mind, this is a general overview of how the Ontario healthcare system works, your circumstance is always unique to you.
The following is an overview of what happens after the hospital discharge process:
Notification of Discharge – The hospital notifies the family or substitute decision maker (SDM) that they plan on discharging the client. This notice can be as short as a day or as long as a week in advance of discharging the client.
The Needs Assessment is Completed – The hospital discharge planner or social worker (SW) assists the family or SDM with the arrangements that need to be made for a successful discharge. The discharge planner typically does not make the arrangements but identifies what needs to be done.
Coordination – Generally, the family or SDM is responsible for coordinating the various services that may be needed, such as booking follow-up physician appointments, arranging household details (e.g., food, removing old prescriptions, placing new prescriptions), and ensuring the home environment is safe, especially if the client has limitations. However, HCCSS can also assist with the coordination of home care services if necessary.
HCCSS Integration – The hospital works with Ontario Health and Home and Community Care Support Services (HCCSS), who determine the client’s eligibility for government-funded “home care” services, including a potential number of hours of assistance at home.
Transfer Home – The family/SDM may make arrangements to transfer the client home themselves, or if required, transportation services can be arranged either through healthcare services or an ambulance through the hospital.
Ongoing Supervision of Care and Health – Many factors contribute to a successful transition back into the community. Maintaining a clean environment, good nutrition, mental stimulation, socialization, and exercise all contribute to better health outcomes. Transparent and effective communication between health professionals, coordination of services, and family members/SDM is essential to ensure the client’s well-being.