While most of us prefer to avoid the hospital, there may be times when we require acute hospital care. In Canada, we have basic insured health care coverage, which covers the cost of an acute hospital stay. However, discharge home from the hospital, especially with complex care needs, can be a story of frustration, confusion, and escalating costs with poor outcomes.

In today’s overworked hospital systems, there are often long waits, which can spill over into days of waiting in emergency rooms for admission to a hospital bed for treatment. There are numerous factors at play, including an ever-increasing aging population, millions of people without a primary care doctor to coordinate their care in the community, and health human resource shortages. There is far more demand for hospital beds than the system can provide, so the hospital staff are always under pressure to admit, treat, and then discharge patients back to their homes or communities.

Increasingly, we are hearing from families who are dealing with abrupt hospital discharges with little or no planning for elderly people with complex needs who either don’t have a caregiver at home or have an elderly spouse who cannot safely provide care in the home. In a recent case, the hospital discharge planner informed us that they no longer organize discharge planning meetings with the family unless the patient is having cognitive difficulties. In this particular case, the patient had been in the hospital for a few months, was completely deconditioned, was incontinent with an indwelling catheter and briefs, and unable to sit on the side of the bed without a two-person transfer or a Hoyer (mechanical) lift. The family was told they would be discharging this man in 2 days, on a weekend, no less, and the family was given a 2-page list of medical equipment they should have in place. The family did not know what to do.

For decades, health professional organizations have written about quality standards for discharge from the hospital to home. For families who find themselves in this situation, a good place to start is to understand what exactly high-quality care looks like and what you should request.

In Ontario, quality standards have been established for some time for transitions between hospital and home. Health Quality Ontario, which is now part of Ontario Health, defines the standards:

Quality standards outline what high-quality care looks like for conditions or processes where there are large variations in how care is delivered, or where there are gaps between the care provided in Ontario and the care patients should receive. They:

• Help patients, families, and caregivers know what to ask for in their care
• Help health care professionals know what care they should be offering, based on evidence and expert consensus
• Help health care organizations measure, assess, and improve their performance in caring for patients. [1]

In the referenced document – Quality Standards – Transitions Between Hospital and Home, there are ten Quality Statements (QS) to improve care when transitioning patients from hospital to home. They are listed and edited as follows:

QS 1: Information-Sharing on Admission

Upon admission, the hospital shares information about the admission with the patient’s primary care and home and community care providers, as well as any relevant specialist physicians, via real-time electronic notification soon after admission. These community providers then promptly share all relevant information with the admitting team.

QS 2: Comprehensive Assessment

People receive a comprehensive assessment of their current and evolving health care and social support needs. This assessment is initiated early upon admission and updated regularly throughout the hospital stay to inform the transition plan and optimize the transition process.

QS 3: Patient, Family, and Caregiver Involvement in Transition Planning

People transitioning from hospital to home are involved in planning and developing a written transition plan. If people consent to include them in their “circle of care,” family members, advocates, and caregivers are also involved.

QS 4: Patient, Family, and Caregiver Education, Training, and Support

People transitioning from the hospital to home, along with their families and caregivers, have the information and support they need to manage their healthcare needs after the hospital stay. Before transitioning, they are offered education and training to manage their health care needs at home, including guidance on community-based resources, medications, and medical equipment.

QS 5: Transition Plans

People are given a written transition plan, developed by and agreed upon in partnership with the patient, any involved caregivers, the hospital team, and primary care and home and community care providers before leaving the hospital. Transition plans are shared with the person’s primary care and home and community care providers and any relevant specialist providers within 48 hours of discharge.

QS 6: Coordinated Transitions

People admitted to the hospital have a named health care professional who is responsible for timely transition planning, coordination, and communication. Before people leave the hospital, this person ensures an effective transfer of transition plans and information related to people’s care.

QS 7: Medication Review and Support

People transitioning between the hospital and home have medication reviews on admission, before returning home, and once they are settled at home. These reviews include information on medication reconciliation, adherence, and optimization, as well as guidance on using and accessing medications in the community. A person’s ability to afford out-of-pocket medication costs is considered, and options are provided for those unable to afford these costs.

Q 8: Coordinated Follow-Up Medical Care

People transitioning to home have follow-up medical care with their primary care provider and/or a medical specialist, which is coordinated and booked before they leave the hospital. Individuals without a primary care provider are provided with assistance in finding one.

QS 9: Appropriate and Timely Support for Home and Community Care

People transitioning from hospital to home are assessed for the type, amount, and appropriate timing of home care and community support services they and their caregivers need. When these services are needed, they are arranged before people leave the hospital and are in place when they return home.

QS 10: Out-of-Pocket Costs and Limits of Funded Services

People transitioning from the hospital to home have their ability to pay for any out-of-pocket healthcare costs considered by the healthcare team, and information and alternatives for unaffordable costs are included in their transition plans. The healthcare team explains to people what publicly funded services are available to them and which services they will need to pay for.

In summary, more and more families seem to be struggling with hospital discharges and the lack of transition planning, especially for elderly persons with complex care needs. The first step in addressing a safe discharge is to understand what a high-quality transition plan should include before you move your family member out of the hospital. In a follow-up blog, we’ll discuss an easy outline for families to use when faced with this situation.

[1] https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-transitions-between-hospital-and-home-quality-standard-en.pdf