Here you'll gain insight into how the healthcare system in Ontario works. 

We've taken a fairly common situation - an elderly Client returning home from the hospital, as an example.

Please keep in mind that while it's useful to have an overview of how the "system" works, your circumstances are unique to you. There is no one size fits all Elder care solution.

For the sake of simplicity we've used the term "Client" to describe the elderly individual who is returning home. The term "Client" has replaced "Patient" at many hospitals.

Also, we have numbered and named the steps in the discharge process. In reality no-one actually refers to the steps as separate steps, they are all one process.

1. Notification of Discharge

Usually the hospital will notify the family that they plan on discharging the Client. Notice can be as short as one day or as long as a week in advance of the discharge date.

2. Needs Assessment

The hospital Discharge Planner (or, in some cases Social Worker) will help the family identify the arrangements that need to be made in order for the discharge to be successful. The Discharge Planner is not responsible for actually making the arrangements, although they will, on occasion, assist in making some of them.

3. Coordination

Generally the family is responsible for coordinating all the various services that may need to be put in place, booking follow up doctors appointments and arranging all the household details - making sure food is in the refrigerator, medications are up to date, old prescriptions have been removed from the household, the household environment is safe (with the limitations that the Client now has), etc.

4. CCAC evaluation

Hospitals have a CCAC coordinator (Community Care Access Center - formerly known as Homecare) on-site who determines the number of hours of care the Client is eligible for under the government program. The maximum has recently been reduced from 14 hours a week to 2 hours per week, with the exception of palliative care clients (where the Client is dying) where the maximum is usually 24 hours a day.

Also recently, the loan of hospital beds, commode chairs, grab bars and mattresses has been discontinued. At one time the CCAC coordinator could arrange for a one month loan of hospital beds, grab-bars and other necessary aids that were essential to the safe return home of the Client. At the end of the one month period clients/families could then arrange to buy or rent any equipment that was still needed. From what our sources are telling us, there is no longer any loan period. In cases where these assistive devices are needed they must be arranged for by the family themselves. 

5. Transfer home

The family may make arrangements to transfer the Client home themselves or, if required they can book a transfer ambulance through the hospital.

In an ideal world, all services would be in place and all details have been sorted out prior to the Client's arrival home. In reality, this seldom happens. It is not unusual, for example for clients to return home without their medication, without a new prescription, without an exercise schedule, wheelchair etc.

6. CCAC (Homecare) visits

For most people it is comforting to have a consistent caregiver.

Unfortunately, due to a variety of factors, it is very difficult for CCAC contracted agencies to provide consistent caregivers for clients.

(A note here regarding CCAC caregivers. CCAC contracts independent companies to provide caregivers on its behalf. The CCAC itself does not employ caregivers).

Eldercare Home Health is not a CCAC care provider, although we are fortunate to have a very good relationship with many of the CCAC offices. At Eldercare Home Health we are accountable directly to you and there is always someone to talk to if you have any questions regarding any aspect of the care we provide.

7. Ongoing supervision of care and health

There are many considerations for a successful return home. Having the right care is in place is key, but there are other factors that can also make a significant difference to the health of clients: maintaining a clean environment, nutritional considerations, mental stimulus, socialization, exercise regimen, monitoring changes in health status, communication between health professionals and family members, coordination of services etc.

9. Awareness of change in condition

It is important that the Client's condition is monitored and that a knowledgeable care professional take appropriate action when health changes occur.

At Eldercare Home Health taking care of the elderly is all we do. We know how the healthcare system works, what services our clients are entitled to receive through CCAC and how to access them. We advocate for the well-being of our clients and coordinate and monitor all delivery of services, from equipment to home blood work, medication administration and personal care.

We take a holistic approach to providing care. 

We are usually able to provide consistency in caregivers.

We often are involved with discharging clients home and taking on the responsibilities that would normally fall to the family (we are usually contacted as part of step 2). 

Please feel free to contact us if you have any Elder care questions.