Discharge from Hospital
Eldercare Home Health helps seniors transition safely from hospital to home. Our Registered Nurses coordinate with hospital teams, advocate for your parent during admission, and ensure care is ready the day they leave.
When a crisis brings you there
Seniors who arrive in hospital through a crisis are often unprepared. Communication with the care team can be difficult, and families are frequently left uncertain about what comes next.
Eldercare Home Health caregivers can be on site to assist with meals, mobility, and comfort. A nurse on site also allows families to rest. We have been a trusted resource for hospital social workers throughout the GTA for more than 30 years.
When the admission is planned
Seniors who have planned surgery often know in advance they will need help during recovery, but may not know how much. Many spouses of elderly clients are around the same age and not always able to provide the physical support needed.
Having the right care in place before discharge can prevent complications and enable a faster, safer recovery. We provide care at North York General, Sunnybrook, Baycrest, Humber River, and other GTA hospitals.
Care from hospital to home
The two most common scenarios we come across are seniors who have found themselves in hospital as the result of a sudden crisis, and seniors who have planned surgery. In both cases, having supplemental care while in the hospital can make a real difference.
Often seniors who have found themselves in the hospital as the result of a crisis are completely unprepared for the stress, anxiety, and confusion that can accompany a hospital stay. Seniors and their families often find it difficult to understand what is going on, who is supposed to be doing what, and when. It is at this time of crisis that they realise that the medical community is a world unto itself, with its own way of doing things that can be difficult to navigate.
Eldercare Home Health caregivers can assist hospitalised clients with timely visits to the bathroom, showering, dressing, walking, meals, and more. They can also communicate concerns to the hospital staff and our own Registered Nurses, to help ensure action is taken when required. Knowing a caregiver is on site can also provide the reassurance families need, so that they themselves can take a break. Eldercare Home Health has been a trusted resource to social workers in hospitals throughout the GTA since 1995. We understand the hospital environment and the many challenges. We can help both during the hospital stay as well as with the discharge and return home.
Social workers and hospital resources
It is important for families to understand that there are people at the hospital who can help. A social worker can help you understand what is going on, what your options are, and what to expect. Your social worker can also, when the time comes, help you access resources in preparation for discharge.
Planned surgery and recovery at home
Seniors who have planned surgery often know that they will need help during their recovery, but sometimes underestimate just how much. The majority of seniors who have spouses have spouses who are a similar age to them. Depending on the type of surgery, recovery can take weeks. It can be exhausting helping someone 24 hours a day during this period. Having the right care in place at the right time can help prevent problems, ensure the client is safe, reduce the hospital stay, and allow the client to return home sooner.
Step 1 – During the initial phone inquiry we'll ask: Who you are calling about (friend, relative, etc.), their age, recent health issues, mobility, medications. If there has been a recent physical change such as a rapid loss of weight, a fall(s), surgery, a sudden change in cognitive status, etc. What your key concerns are and what would you like the outcome to be. If the senior requiring care is competent and “on board” — prepared to accept care? How soon you would like to have care in place. Most often a Registered Nurse will be available to talk with when you call. If none is available, a Registered Nurse will review the notes taken when you first called and call you back promptly.
Step 2 – Assessment by a Registered Nurse: If you and the Registered Nurse (see above) agree that it would be helpful to go the next step, a no-charge, no-obligation on site assessment is arranged. This assessment allows the Registered Nurse to meet with the senior requiring care and assess their condition from a Registered Nurse's perspective. The Nurse will often talk with the Social Worker and other members of the hospital team to ensure that she has as complete a picture as possible. The assessment also provides an opportunity for you and the family, or anyone else involved in care decisions to have any questions answered. Note: All assessments are conducted by a Registered Nurse.
Step 3 – Care plan – proposed by the Registered Nurse: The plan will include identifying desired outcomes and the responsibilities of the caregivers. The Nurse will propose a schedule for care, including duration and frequency of shifts. A Registered Nurse will be assigned to case manage all care. The Registered Nurse will be your key contact person and will be involved with selecting the appropriate caregivers and supervising all care. She will also personally visit the client on a regular basis. The Registered Nurse Case Manager will liaise with the client's Doctor(s), Pharmacist and other healthcare professionals, coordinate hospital discharge, and more. There is no added fee for Case Management by the Registered Nurse.
You will be asked to sign a care agreement that, in essence, says that you are hiring us to provide care and have agreed to our rates. There is no additional fee for the involvement of the RN Case Manager. You are not locked into a set number of weeks or number of hours per week, although the minimum for an individual shift is 4 hours. Invoices can be paid by cheque or electronically through any of the major banks. With the agreement signed, the Registered Nurse Case Manager will identify caregivers with the appropriate skill set, personality, and experience. All our caregivers are employees of Eldercare Home Health. All staff are insured, bonded, and covered by WSIB.
Five steps to care
Below are the steps Eldercare Home Health takes when arranging care for seniors in hospital and at discharge.
- 1
Initial enquiry
We ask about the person you are calling about, any recent changes in health, your key concerns, and how soon care is needed. A Registered Nurse is usually available to speak with you directly.
- 2
Assessment by a Registered Nurse
A Registered Nurse visits to meet the client, review their health status and environment, and speak with the care team if in hospital or a facility. All assessments are conducted by a Registered Nurse.
- 3
Care plan
The nurse proposes a schedule with identified outcomes, hours, and caregiver type. A Registered Nurse Case Manager is assigned to oversee all care and liaise with the client's physicians and pharmacists. There is no added fee for nursing case management.
- 4
Care agreement
You review and sign a care agreement. There is no lock-in; you can cancel with short notice. Invoices are payable by cheque or through your bank.
- 5
Care begins
The Registered Nurse Case Manager selects and introduces the caregiver. Our caregivers are Eldercare employees, not contractors. All staff carry liability insurance and are supervised throughout.