Source: The Care Guide

Definition of Discharge Planning

Social workers engaged in discharge planning coordinate discharges for patients by collaborating with the patient, family, health care team and community resources. The social worker is involved with the early identification and assessment of the patient's needs and implements timely discharge plans that result in continuity of care and efficient use of hospital and community resources.

Discharge planning is a process that includes identification, assessment, goal setting, planning, implementation, coordination and evaluation.

Source: The Association of Discharge Planning Coordinators of Ontario (ADPCO). Hospital Discharge Planning: A Balancing Act, May 1997.

Components of Discharge Planning

In order to coordinate timely discharge plans, the social worker uses the discharge planning process to:

1. Promote early identification and assessment of patients requiring assistance with planning for discharge.
2. Collaborate with the patient, family and health care team to facilitate planning for discharge.
3. Recommend options for the continuing care of the patient and refer to accommodation, programs or services that meet the patient's assessed needs and preferences.
4. Liaise with community agencies and care facilities to promote patient access and to address gaps in service.
5. Provide support and encouragement to patients and families during the stages of assessment and discharge from the hospital.

Source: The Canadian Association of Discharge Planning and Continuity of Care (CADPACC) : Guidelines and Standards for Discharge Planning Coordinators, May 1995.

Some Discharge Options

Depending on the care needs of the patient, there are a variety of possible options for discharge. Some of these options include:

• Home alone with family support
• Home with private agency supports such as nurses, sitters, personal care workers, health care aides
• Home with support from community agencies such as Meals on Wheels, seniors support services
• Home with CCAC (Home Care) support if eligible
• Retirement home for short-term convalescence or for a permanent stay
• Supervised boarding home
• Rehabilitation services such as Geriatric, Stroke and Head Injury
• Return to the referring hospital
• Long-term Care facility (nursing home)
• Complex Continuing Care facility (chronic care)
• Palliative Care hospital/hospice

Retirement Homes

Retirement homes are privately owned and operated residences. Each home provides accommodation, meals and recreational activities. The assistance they offer varies and can include help with bathing, supervision of medication and assistance with dressing. Some homes include all services in their costs that can range from approximately $1,500 to $4,000 per month depending on the type of room and services provided. Assisted Living units are available in some residences at a greater cost. Some other residences do not provide a separate Assisted Living unit, but bring the increased care to your room. Check with the individual retirement home to determine what services are available and whether they can meet your care needs.

Applications are made directly to the retirement home. A very small number of these residences have subsidized beds that are administered by the City of Ottawa.

On-line guides exist to assist in the selection of a retirement home:

The Ontario Residential Care Association
The Care Guide - Care Planning Partners Ltd

Convalescent care and respite care convalescent care is designed to offer a period of recuperation for individuals recently hospitalized who may need additional care to recover their strength, endurance and functioning.

Respite Care offers a period of rest to family caregivers of people living in their own home by allowing the patient to enter a care facility for a short period of time. These services may help individuals remain in their homes as long as possible.

Convalescent and Respite Care in Retirement Homes

Retirement Homes offer short-term accommodation for convalescence (usually under 1 month stay) and respite care. These homes are privately operated and services vary from home to home such as medication administration, personal care and assistance to the dining room. If you are fairly independent, the cost is approximately $50-$100/day depending on the residence. If you need increased care the cost could be higher. In many facilities the convalescent/respite costs are at a reduced rate for the initial period and will increase after a period of time (usually 1 month).

While you are in hospital, your social worker will provide you with the necessary information and assist you with the discharge process. Some facilities will ask social workers to provide a written assessment of your level of functioning and specific care needs. Any agreements regarding room rates, cost for various amenities (e.g. telephone, cable) and additional costs for personal care are made directly between you and the facility.

If you are aware that you will be coming in to hospital for surgery, it can helpful to tour some of the retirement homes that provide convalescent care before your surgery date to determine which ones you like. This can also help you know what to expect should you go to a retirement home for convalescence upon your discharge.

Short Stay Program

Another option for convalescent (supportive) care and respite care is the Short Stay Program available at a few Long-term Care facilities (nursing homes). These beds are administered by the Community Care Access Centre (CCAC). If you are in hospital, your social worker will assist with the application process. From home, you can call the CCAC at 613-745-5525 for information.

Long-term Care Placement

Making the decision to apply for long-term care placement can be a difficult and emotional process. It is not easy to know when the time has come to make this very significant change in one's life. You may wish to involve family members or other support persons in your decision making. While in hospital, your social worker and other members of the health care team can also help.

Referral and Application to Long-term Care

You may refer yourself or someone else may refer you. If you are in hospital, your social worker will make the referral and will complete the application process to ensure all the necessary forms are submitted. Once they are completed, the forms are forwarded to the local Community Care Access Centre (CCAC). The CCAC will determine your eligibility for long-term care placement and ensure that you are put on an appropriate waitlist for the facilities you have chosen.

Awaiting Placement From Hospital

If you are going to await placement from hospital, there are specific guidelines to follow. Your social worker will explain these to you.

Awaiting Placement From Home

If you plan to await long-term care placement from home, you may select any facility of your choosing. The CCAC will assist with the application process, determine your eligibility and place you on the waitlists for your chosen facilities. Further information about placement from home can be found on the OACCAC's web site.