How the Ontario Healthcare System & the CCAC/LHIN can help you!

One of the most common questions we get is what happens once a client is returning to the community from the hospital!

*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 – Hospital notifies family or the 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 – Hospital discharge planner/SW helps the family or SDM of arrangements that need to be made in order for the discharge to be successful. The discharge planner usually does not make the arrangements, but instead identifies the arrangements need to be made.
  • 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 such as food, removing old prescriptions, placing new prescriptions in the household, ensuring home environment is safe in consideration to clients limitations if they have any.
  • CCAC/LHIN Integration – Hospitals have a local health integration network  coordinator on-site who determines number of “home care” hours a client is eligible for under the government program.
  • Transfer Home – Family/SDM may make arrangements to transfer the client home themselves or if required can book transportation services either through our healthcare services or an ambulance through the hospital.
  • Ongoing Supervision of Care and Health – Many factors contribute to a successful return of a client back in the community. But maintaining a clean environment, nutrition, mental stimulus, socialization, exercise, monitoring all contribute to better health outcomes. Transparent and effective communication between health professionals, coordination of services and family members/SDM is a priority.


Please click on any of the following links for more information