In this guide
The call often comes with little warning: "Your mother is being discharged tomorrow." Hospitals in Ontario are busy, and once a patient no longer needs hospital-level care, the team starts planning for them to go home quickly. That is good news, but it can leave a family with a long list and very little time.
This checklist is meant to make those few days calmer. It covers what to ask before discharge, how to prepare the home, and how to get through the first week.
Before discharge: what to ask the hospital team
Most hospitals have a discharge planner, a social worker or a patient care coordinator who helps plan the move home. Ask to speak with them as early as you can, ideally a few days before the expected date. Bring a notebook, or ask if you can record the key points on your phone.
- What is the plan, in writing? Ask for the discharge summary or instructions on paper, not only explained at the bedside.
- Which medications are new, changed or stopped? Ask for an updated list and whether prescriptions will be sent to your usual pharmacy.
- What follow-up appointments are needed? Family doctor, specialist, bloodwork, imaging. Ask who books them.
- What can and can't they do yet? Walking, stairs, bathing, lifting, driving, diet.
- What signs mean we should call or go back? Get this in plain words, and write down who to call after hours.
- Has a referral been made to Ontario Health atHome? This is the provincial agency that arranges publicly funded home care.
- What equipment is needed? Walker, raised toilet seat, shower chair, grab bars, a hospital bed. Ask who arranges it and when it arrives.
If you are not sure a parent is ready to go home safely, say so clearly and ask what the options are. You are part of the care team, and your knowledge of the home and the person matters.
Who to ask what
Different people in the hospital can answer different questions. Tell the team you are the family caregiver and what you can and cannot do at home. If you can, ask each of them before the day of discharge, and write the answers down.
The doctor
- What is the diagnosis, and what should we expect over the next few weeks?
- Which medications are new, changed or stopped, and why?
- What warning signs mean we should call, and who do we call after hours?
- Which follow-up appointments and tests are needed, and who books them?
- Are there limits on food, activity or driving?
- Which symptoms are normal for this condition, and which are not?
- Should we see the family doctor in the first week after going home, and who sends them the discharge summary?
The hospital's occupational therapist (OT) and physiotherapist, if they have seen your parent
- Can my parent walk, climb stairs, get on and off the toilet and in and out of bed safely, and with what help?
- Do they need a walker, a cane, a shower chair, a raised toilet seat or a hospital bed, and who arranges and sizes it?
- Does my parent need someone with them when bathing, dressing or moving around?
- Did you recommend any changes to the home, such as grab bars? Is a home visit needed?
- Can you show me how to help with anything that needs a technique, such as getting in and out of bed, a transfer or a dressing?
- What exercises should my parent do at home, and when does physiotherapy start?
The discharge planner, social worker or care coordinator
- Which public services have been approved, and what is the date and time of each first visit?
- Who calls us to book physiotherapy, nursing and personal support, and by when?
- Who covers the first nights and the first few days if the first visit is later?
- Who do we call if nobody has called us by the day after discharge?
- Is transportation home arranged, and does my parent have their keys and a way into the home?
- What will any of this cost, and who do we pay?
- Who gets the discharge summary?
Publicly funded home care: Ontario Health atHome
Ontario Health atHome coordinates government-funded care at home, including nursing, personal support, therapy and medical supplies. Care coordinators work with people in the community and people leaving hospital to decide what help is needed and to arrange it. Eligible services are covered by OHIP.
You can reach Ontario Health atHome at 310-2222 (no area code). The City of Toronto lists the same number for help after a hospital discharge and for applying to long-term care.
Do not assume care starts the day your parent gets home. Being referred is not the same as having a visit booked. The first personal support visit, the nurse and physiotherapy or other therapy are often scheduled separately, and the first visit can be days after discharge. Before you leave the hospital, ask:
- Which services have been approved, and what is the date and time of each first visit?
- Who calls us to book physiotherapy, and what do we do if nobody has called by the day after discharge?
- Who covers the nights and the first few days until the first visit?
If the answer is "someone will call", write down who and when, and call Ontario Health atHome at 310-2222 the next day if you have heard nothing. If there is a gap, that is when a private caregiver can be there from the first night, while the public plan gets started.
A few things families often find helpful to know:
- Publicly funded visits are assigned based on assessed need, so the hours may be fewer than a family expects. Ask what has been approved and for how long.
- Visits are usually scheduled in blocks, not around the clock.
- Needs change in the first weeks. If things are harder than expected, call back and ask for a reassessment.
Get the home ready before the trip home
You do not need to renovate. Focus on the rooms your parent will use in the first week.
- The way in. Clear the path from the car to the door. Check railings, steps and lighting.
- The bedroom. If stairs are hard, consider setting up a bed on the main floor for now. Keep a lamp, water, phone and charger within reach.
- The bathroom. This is where many falls happen. A non-slip mat, a shower chair, a raised toilet seat and a night light make a real difference.
- The kitchen. Stock easy meals for a few days. Move everyday items to counter height.
- Medications. Pick up prescriptions before or on the day of discharge. A weekly pill organizer helps keep track.
Want a professional to check the home first? An occupational therapist (OT) can visit the home, mark where grab bars and rails should go, recommend equipment, and check that the walker, the bed and the bathroom suit how your parent moves. A private OT visit is paid for by the family. RightKind Home Access can arrange an OT visit and, if you want, the grab bars and other changes, done by our contractor partner. Call as early as you can, because installation takes time.
For a fuller list, see our room-by-room fall prevention checklist.
The first 72 hours
The first three days are usually the hardest. Your parent is tired, routines are new, and small problems feel big.
- Plan who is there. Make a simple schedule of who is staying, especially overnight on the first night.
- Keep the papers together. Discharge instructions, medication list, appointment dates and phone numbers in one folder by the bed.
- Watch the basics. Eating, drinking, getting to the bathroom safely, sleep, and pain.
- Write things down. A short daily note helps when you call the doctor or the care coordinator.
- Ask for help early. If you are running on empty by day two, that is normal. It is a sign to add support, not a sign you are failing.
When private help makes sense
Public home care is valuable, but it rarely covers every hour a family needs. Private, non-medical support can fill the gaps: someone at home overnight for the first week, help with bathing and dressing, a companion while family members work, or a person to stay with your parent at the hospital before discharge.
At RightKind Care™, a care coordinator can arrange a personal support worker (PSW) for exactly those hours, and work alongside the publicly funded plan rather than replace it. Medical care stays with your parent's doctor and health team. See recovery and respite care and hospital advocacy for what that support looks like.
Questions families ask
How much notice do families usually get before a hospital discharge?
It varies by hospital and by situation. Sometimes it is a few days, sometimes less than a day. Ask the team for the expected discharge date as early as possible and check in each day.
Can a family refuse a discharge if they feel it is not safe?
You can raise concerns and ask for a meeting with the care team to talk through the plan and the options. Be specific about what worries you, such as stairs, being alone at night or managing medications.
Does Ontario Health atHome cost anything?
Eligible home care services arranged by Ontario Health atHome are covered by OHIP. Private services that a family arranges on its own are paid by the family.
Will care and physiotherapy start as soon as my parent is home?
Not always. A referral does not mean a visit is booked. Ask the hospital team and Ontario Health atHome for the date and time of each first visit, including physiotherapy, and plan who will help in the days before they start. Private support can cover that gap.
What should we do if things get harder at home after discharge?
Call the care coordinator at Ontario Health atHome and ask for a reassessment, and contact the family doctor about any medical changes. If you need more hours of help than are available, private support can be added.
Who can check that the home is safe before my parent comes back?
An occupational therapist can visit and make recommendations, and the family pays for a private visit. RightKind Home Access can arrange the visit and, if you want, the changes it recommends. Ask the hospital team too whether they have already recommended equipment.
Sources
Moshe started RightKind Care after his own family needed extra help at home. He writes these guides so other families have the plain answers he wished he had. Read his story →
