Planning for your care needs

Planning to leave the hospital, called discharge, begins soon after you are admitted. You are discharged when your health care team decides that you no longer need medical care at the hospital.

We know that preparing for discharge can feel confusing and overwhelming, especially at the beginning of your care journey. Your care team will work with you and your family to provide the best plan possible for your return home.

How does discharge work at UHN?

After you are admitted to the hospital, your health care team will work with you to plan your care goals and for the day when you leave the hospital. This is called your day of discharge.

You will find out your day of discharge within 1 to 2 days after you are admitted. Knowing which day you will leave the hospital can help you and your family plan ahead. Your health care team can also arrange any follow-up care you may need in time for when you leave the hospital.

Sometimes patients may be transferred to a different unit or one of UHN’s other hospital sites during their hospital stay. This depends on your care needs. The UHN hospital sites include:

• Princess Margaret Cancer Centre
• Toronto General Hospital
• Toronto Western Hospital
• Toronto Rehab
  • University Centre
  • Bickle Centre
  • Lyndhurst Centre
• Hillcrest Reactivation Centre

Your health care team will keep you informed of any possible transfers. No matter which site you are at, they will always help you prepare to leave the hospital.

Where will I go after I’m discharged?

Going home is the first choice for patients. This is called the home first approach. If you need help when you return home, your UHN health care team will help you make those plans.

If you need care at home, Home and Community Care Support Services will talk to you about your care needs and any resources in the community that may be right for you. They may contact you virtually (by phone) or in person, depending on your situation. Ask your health care team for more information.

What if my needs can’t be met at home?

If your needs cannot be met at home, your health care team will work with you to decide what type of facility can best provide the care you need.

This could mean going to a care site that provides you with the supports you need before you move back into the community. A care site could include:

• Inpatient Rehabilitation
• a Reintegration Unit (RIU)
• a Transitional Care Unit
• Complex Continuing Care (CCC)
• Convalescent Care
• Palliative Care
• a hospital in your home community or the hospital you were sent to UHN from

If you are eligible for one or more of these care sites, your health care team will help you apply to and transfer there.

If your needs cannot be met at home for the longer term, your health care team will help you start the process of deciding whether you can apply to a care site such as a retirement home, supportive housing, or Long-Term Care (LTC), if you are eligible.

What do I need to do to prepare for discharge?

Once you know your day of discharge, you need to arrange your own transportation home. If you need help, ask your health care team for a list of phone numbers for travel options, such as an ambulance, taxi or wheelchair accessible taxi.

On your day of discharge, you will be moved out of your room by 10:00 am. You can wait on the unit, outside of your room, until your transportation arrives. Your health care team will complete your discharge paperwork before you leave.

Note: UHN does not pay for your transportation to leave the hospital.

Who do I contact if I have questions about leaving the hospital?

Speak with any member of your care team. They are here to support you.

Your health care team

Your medical team will help care for you while you are in the hospital. Your medical team will include:

• Attending Physician: A doctor who is in charge of your care while you are in hospital. They also supervise the fellows, residents, or medical students who may also be involved in your care.
• Resident or Fellow: A doctor who is completing their training in a medical specialty at the hospital.
• Nurses: Keep track of your health and well-being, and teach you about your illness or injury. They also supervise nursing students who may also be involved in your care. Each day, you may have 2 to 3 different nurses.

And may include:

• Consulting Physician: A specialist doctor who is asked by the Attending Physician to give recommendations about specific aspects of your care. They also supervise the fellows, residents, or medical students who may also be involved with the consultation.
• Physician Assistant (PA): A medically educated clinician who works with the doctors. They help assess and manage your health and medical needs while you are in the hospital.
• Nurse Practitioner (NP): A nurse who has additional education and specialized training to assess and manage your medical needs and plan your care. They can make diagnoses, order tests, interpret results, and prescribe medications.

Depending on your needs, Allied Health staff may also help care for you and help you prepare to leave the hospital. This could include:

• Dietitian: Helps you choose the right foods for your meal planning.
• Occupational Therapist: Helps you plan how to safely do everyday activities such as eating, bathing and getting dressed.
• Physiotherapist: Helps you plan how to be more independent by building your strength, balance and coordination.
• Social Worker: Helps you manage your feelings, relationships and money needs. They may help you plan for when you go home.
• Speech-Language Pathologist: Helps with problems talking or swallowing.