Community resources for Ontario families
A plain-English guide to what happens when someone comes home from hospital, where publicly funded care stops and private care starts, and a directory of organizations worth knowing about. Every link on this page was checked and is live.
This is a general overview of how the Ontario system works. Every situation is different, and a care plan is always built around the individual.
What happens after a hospital discharge
You are told discharge is being planned
The hospital notifies the family or Substitute Decision Maker. Notice can be as short as 24 hours, so it is worth asking early what the expected date is.
A needs assessment is done
A discharge planner or social worker assesses what is needed for a safe return home — care needs, equipment and supports. They guide the process, but families and SDMs usually take the lead on arranging services.
Services get coordinated
Usually by the family: booking follow-up appointments, sorting medications (clearing old ones, organizing new prescriptions), and preparing the home for safety, food and accessibility.
Ontario Health atHome is brought in
The hospital connects the client with Ontario Health atHome (formerly Home and Community Care Support Services). They assess eligibility for publicly funded home care, decide the type and amount of support — PSW visits, nursing, therapy — and build a care plan from the clinical needs.
Transfer home
Arranged privately, or by hospital medical transport where that is clinically required.
Ongoing care and supervision
A transition holds together when the basics do: a clean and safe home, proper nutrition and hydration, mental stimulation and company, and regular communication between the family and the care providers.
Where publicly funded care stops
Ontario Health atHome provides real, government-funded support — but the hours and scope are limited, and they rarely cover everything a household actually needs. That gap is usually where families start looking privately.
You can use both. Many of our clients receive funded hours and top them up with us for evenings, overnights and weekends.
What we add
- Flexible hours built around your schedule
- Faster start — no long waitlist
- The same caregivers, for continuity
- Cover beyond funded hours: evenings, overnight, 24/7
- Help with discharge coordination and setting the home up
Directory of community resources
Organizations across Ontario and Canada that families ask us about. We checked every link — if one stops working, tell us and we will fix it.
Home care and general support
Dementia and Alzheimer’s
Condition-specific organizations
Palliative and hospice care
Children, youth and families
Seniors, caregivers and advocacy
Money, benefits and tax
More from Help Now
- Where to start — if you are at the very beginning of this
- Frequently asked questions
- How a custom care plan is built
- Care scenarios — what home care looks like in practice
- Our blog — costs, hours, and how to choose
- Locations — and local resources by province
Navigating this after a hospital stay is genuinely overwhelming, and you do not have to work it out alone. Whether you end up with funded care, private care or both, the goal is the same — a safe return home. Call us on 1-888-507-6236 and we will talk it through, free.