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Practical Insights for Busy Caregivers

How care coordinators can help you plan for your relative’s discharge from hospital


October 14, 2017, by Paul Cavanagh,

If you have a relative returning home from hospital, chances are they’re going to need assistance with a whole host of things: new medications, attending follow-up medical appointments, managing day-to-day activities, coping with the emotional fallout of their illness. The list goes on. Who’s going to help them with all these things? you wonder. You may be worried that you’re expected to somehow manage it all yourself.
Care coordinators in Ontario hospitals
The good news is that your choices aren’t necessarily as limited as they may seem. In many Ontario hospitals, you’ll find care coordinators ready to help you create a care plan that takes advantage of a variety resources, including some you may not be aware of.
Kristina McLaughlin is a care coordinator with the South West Local Health Integration Network - Home and Community Care (formerly the South West Community Care Access Centre). She works at the Acute Care for the Elderly program at Victoria Hospital in London, Ontario.
First discussion
When McLaughlin first meets with a family, she asks them to start jotting down what areas of life they think will be challenging once their relative returns home. She also asks them to think of all the different people who may already be helping their relative at home, everyone from friends, neighbours, family, to formal services. If the family isn’t familiar with what formal services are available, she’ll suggest they take a look at or before they meet again. She may also tell the family how they can learn more about their relative’s medical condition.
Follow-up discussion
McLaughlin generally talks with the family again a few days before discharge. By then, they will have had a chance to think through some of the topics raised in their first conversation. The discussion starts to focus on what it’s going to take to support their relative at home. Often, formal home care services are part of the solution; however, care plans usually involve many different people and programs chipping in to provide support.
“I feel as though the best possible plans that I’ve ever put in place for a person going home come together with feedback from a number of different people that are part of that person’s life,” McLaughlin says. “I need to hear all of those perspectives. I need to hear how many times a day are the neighbours being called, I need to hear how many times are you – their son or daughter –being called, and what are those phone calls looking like, and how are you managing with that?”
She routinely tells family caregivers, “The person who’s going home is only going to be as confident as… you (are). So we need you supported, and we need you to know what’s going on… so that you can share that energy of being confident with the patient.”
Discharge options
Going directly home from hospital may not be the best option for the patient. If this is the case, McLaughlin will help the patient and family explore other options like convalescent care or respite in a retirement home. In some situations, where care needs are likely to remain great, moving to a long-term care home might be the best option.
Heads up to community agencies
If the patient is already receiving support from a community agency, McLaughlin and the treatment team can update the agency on any change in medical condition so that the transition back to the community is as smooth as possible. For instance, if the patient usually attends an adult day program, it’s important for program staff to know how the patient’s abilities or needs have changed so that they can accommodate them. If the patient needs Meals on Wheels but can’t come to the door when meals are delivered, potential solutions might include a lock box or leaving the food in an alternate location.
How do I find a care coordinator?
Not all hospital services have care coordinators connected as closely to them as the Acute Care for the Elderly program does. You may have to specifically request to see one. If connecting with one through the hospital proves difficult, try calling your Local Health Integration Network at 310-2222. If a care coordinator isn’t available, ask to talk to someone at the hospital about your relative’s discharge plan, preferably someone with knowledge of community resources, like a social worker.
A few tips to keep in mind
  • Learn what you can about your relative’s medical condition. A good online resource is MedlinePlus, which offers reliable, up-to-date information about diseases and conditions in language you can understand (produced by the National Library of Medicine in the US). Also, talk to medical and nursing staff or other members of the treatment team.
  • Jot down the things that will likely be challenging for your relative when they return home. Update the list as discharge approaches. These items will all need to be covered off in a discharge plan. The hospital has an obligation to help you develop this plan.
  • Don’t default to looking after all of the items on the list yourself. Map out who’s already involved in supporting your relative or who could be called upon to do so. Don’t overlook friends, neighbours, acquaintances, and other family members who are willing to do “little things” like pay your relative a visit, buy them groceries, take them out for coffee, chat with them on the phone, look up things for them online, etc. The little things can add up. Some people may be willing to do more, if asked.
  • Your family may want to request a meeting with the people at the hospital involved in your relative’s care. Use the meeting as an opportunity for problem solving. If you can’t make it into the hospital, ask that you be allowed to call in by phone.
  • Involve your relative in discussions. Plan with them instead of for them.
  • If you’re going to be looking after some of your relative’s care yourself (e.g. dressing changes, injections, lifts and transfers), get a member of the hospital staff to show you how to do it safely.
See also:
Surviving a relative's return home from hospital


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All is great on paper but thats about it. I asked for help and discharge planner came in and asked 2 questions - how many stairs and if lived alone. I think she only came in just for a show. I said but I work full time. Now delay in aftercare since all drs on vacation and dr sick so 6 weeks after massive MI my mom finally sees specialist says zero exertion and cant be left alone. I have been working full time and trying to balance all - feels like nobody listened when I asked for help prior to discharge. She couldnt even walk past the doorway of hospital room. Action instead of words and plans on paper is what is needed! Thanks