Resource Guide for Family Caregivers
Discharge from the hospital

There is much to consider prior to the care receiver being discharged from hospital; what is relevant will vary depending upon the condition and circumstances of the care receiver. If the care receiver was on the Home and Community Care Program before going into hospital, you will want to notify the nurse on the unit to arrange for a reassessment prior to discharge. It is the nurse’s role to contact the Hospital Liaison Nurse (or whoever else has responsibility for discharge planning). This is necessary to determine whether the home care plan needs to be modified in light of the hospital stay, and/or to reinstate services in the home upon arrival.

If the care receiver was not on the Home and Community Care Program before coming into the hospital, and will now require assistance at home upon discharge, you will want to notify the nurse on the unit so that he/she could co- ordinate the necessary steps.

Discharge planning conference

When changes to the care recipient’s health or level of care required are extensive or complex, a discharge planning conference (usually facilitated by a social worker) will enable joint problem solving and coordination of a plan of care.

Both you and the care receiver (if able) should attend along with all who are directly involved such as:

  • Physician/specialist (often unable to attend)
  • RN
  • SOcial worker
  • Dietician / nutritionist
  • Physiotherapist
  • Occupational therapist
  • Hospital Liaison Nurse, Long Term Care or Continuing Care Case Manager, Residential Care Coordinator

Your preparation should include writing out questions or areas you are unsure of, and any concerns you and the care receiver have identified. During the meeting, be prepared to ask lots of questions regarding needs, arrangements, who to contact and how, costs, etc. and take notes yourself. Likely there will be considerable detail of which to keep track. Ensure that your responsibilities in the plan are within your capability and resources, and that you and others are clear about these agreements.

Notes should also be taken to document the discussion and conclusions of the conference (you may even want to ask if it is okay to tape-record the meeting so that you can review the planning details at your leisure. However, you may not receive permission from everyone in attendance to do this, and if so, you will have to rely on your own notes). If minutes are taken, you and/or the care receiver should receive a copy to ensure that all agreements are clear.

The Plan

It is essential that there is a realistic and detailed plan to cover care needs at home, which may include, but are not limited to:

  • adequate personnel to help with personal care (i.e., home support services). If the individual received these services before, they may need to be enhanced during convalescence. The Community Liaison Nurse or Case Manager or Residential Care Coordinator will be needed for a reassessment or to authorize the changes. If new services are required, a referral to Long Term Care or Continuing Community Care is necessary. What is available in your community, how the plan of care is set up, hours of care allotted, consistency of worker, and cost are a few significant questions. Ensure that you have the name and phone number of any of the above people who may be involved in the arrangements.
  • health care professional referrals for nursing care, physiotherapy, occupational therapy, or a clinical dietician/nutritionist.
  • structural changes to the home, i.e., bathroom grab bars, wheelchair ramp, etc. (An occupational therapist, if available, will be helpful to do a home assessment if this is necessary).
  • new equipment required (i.e., lifting devices, a special bed, or mobility aides such as a specially fitted cane or walker). These items may need to be purchased or borrowed, and arrangements may fall to you. (Agencies that loan medical equipment may be available in your area, and should be explored, particularly if the item is to be used short term, or if it requires a period of trial.)
  • supplies such as incontinent products, or dressing ointment and gauze.
  • new medication or changes in the current regimen with written instructions, including the drug name(s), amount, and time of day to be taken, and any special advice about managing them. (Note: at the time of actual discharge, ensure that you know when the last dose of each medication was given in the hospital).
  • other community supports that may be needed. (See Section 7)

If the hospitalization results in a necessary change in the care receiver’s living situation, such as a move to more supportive housing, to a care facility, or to a rehabilitation facility, discharge planning will need to include a clear description of the options and choices available. Wherever possible, a visit to the new prospective location is advisable so that planning for the move and transition is realistic and sensitive to the impact such a change will have on both you and the care receiver. (See Sections 8 and 10).