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Transition To Community LivingOur dedicated team of therapists will work with you and your family to identify what is needed to facilitate your transition to community living. This may include:

  • Specific day-to-day abilities (e.g. climbing stairs, getting dressed)
  • Use of equipment (e.g. walkers, orthotics)
  • Potential home modifications (e.g. ramps, lifts)
  • Access to community services (e.g. Community Care Access Centre (CCAC))
  • Any relevant additional information (e.g. managing my medication, dietary plans)

Our therapists will also provide you with information on what you can do to maintain your level of success after discharge from the active treatment program. If an issue related to your TOHRC treatment arises and your family physician cannot manage it, you can call and speak with the nurse, as indicated on your discharge plan.

Discharge Planning

During your inpatient stay, a discharge plan will be developed to allow you to manage safe community living according to your specific needs. The most important people involved in planning for your discharge are yourself, members of your family or close friends, and all members of TOHRC rehabilitation team. Other key participants are the community agencies who will arrange or provide you with community-based services.

Development of your discharge plan begins early in rehabilitation, usually by setting goals with the help of your therapist. The overall goal is to maintain the benefits derived from your rehabilitation.

Our social workers are responsible for the coordination and implementation of the discharge plan. They address issues such as finance and funding, home support, transportation and housing, as well as provide information about other community resources that can support you and your family.

During your stay at TOHRC, you will be able to discuss your feelings about your physical disability and its impact on you, your family and your involvement in the community. Your family members and other caregivers will be taught the skills necessary to properly and safely assist you and will also be given the opportunity to discuss the disability’s impact on them and how they are coping.

FAQ About Discharge Planning

TOHRC is committed to supporting you in accessing the services that will most adequately serve your needs. Below is a list of questions that will hopefully answer many of the questions you may have about how your discharge plan is developed and TOHRC police concerning inpatient discharge.

What is discharge planning?
Discharge planning is the development of a plan for managing community living following rehabilitation. Development of your discharge plan begins early in rehabilitation, usually by setting goals in conjunction with your TOHRC interdisciplinary team. Discharge planning has the overall goal of maintaining the benefits derived from your inpatient rehabilitation.

What are the important issues addressed by your discharge plan?
In your discharge plan, you will identify a safe place to live after leaving TOHRC. That place may be your present home, but it may mean moving to another house or residence. You may want to consult with family and rehabilitation team members about a realistic plan to meet your physical, social, cognitive and cultural needs. You will have to decide about your required personal care and assistance. If you require care, you will have to identify who your caregivers will be. They may be family members or paid personal care providers. Whoever you choose as a caregiver will need to be taught the skills necessary to properly assist you.

It may be recommended that you continue to receive rehabilitation after your discharge. You may have to decide between treatment as a TOHRC outpatient, through the Community Care Access Centre if you qualify, or through a private, fee-for-service agency. Your decision will depend in part on the availability of services and your financial resources.

You may also have to address special equipment needs and related financing as prescribed and recommended by your rehabilitation team. If financing is a problem, you can speak with your social worker during discharge planning. You may also want to discuss the implications of your physical/cognitive disability related to your feelings about yourself, your family and your role within the family.

Finally, you may want to explore opportunities for employment and use of leisure time.

Who are the key persons involved in your discharge plan?
The most important persons involved in planning for discharge are you, family members and/or close friends and all members of your rehabilitation team. Other key participants are community agencies who may be arranging or providing services to you in the community. You may want family members or friends to assist you with planning for discharge if your physical/cognitive disability has caused speech, language or memory problems.

What will happen to me if I cannot return to my own house?
While the ideal is to return to your own home, this may not always be possible. You may need a lot of help, meaning you may not be able to return to your present home if no one is available to assist you with self-care and daily-living activities. In this case, you will have to reside in a place where such assistance is available. If you do not have anyone available to look after you, it may be necessary to apply to a retirement home, a supervised residence or a long-term care home.

It may also not be possible to return home because your apartment or house is not accessible. In this case, you will have to make adaptations to your own house or find a place to live that doesn’t have physical barriers.

Where will I go if I cannot live alone?
A TOHRC social worker will meet with you and your family to discuss your need for support prior to discharge in order to provide you with the names of supported service living units, retirement residences or long-term care homes. They will also assist with the application process.

What if my income is too small to pay for equipment or a place to live?
A TOHRC social worker will assess your financial circumstances and identify community agencies that may assist you with this.

Will someone on the rehabilitation team tell me how to make my house accessible and give me ideas about adapting my home to my physical needs?
The occupational therapist will talk with you about your home and, if needed, arrange a visit to determine the changes needed in order for you to live there safely again. The rehabilitation team is interested in having you reside in a place that offers the greatest opportunities for independence while affording you an appropriate level of safety.

When will I be discharged from TOHRC?
Shortly after the team has had an opportunity to assess your rehabilitation needs, an expected date of discharge will be determined and shared with you and your family. You will be discharged from TOHRC when you reach your rehabilitation goals that have been established in conjunction with the treatment team. If initial goals cannot be reached, they will be modified and the team will determine a new date of discharge.

Where will I go if I am unable to go home or to a long-term care residence at the time of discharge?
You may return to the acute care hospital in which you were treated prior to arrival at TOHRC. You will probably remain in the acute care hospital until a long-term care bed is found for you. At the acute care hospital, you and your family can continue to practice the rehabilitation skills taught at TOHRC. The patient’s family is encouraged to remind the acute care staff of your needs. In some cases, your discharge may be delayed by renovations being done to your home. The team will consult with you about the anticipated lengths of delay when deciding if you should return to the acute care hospital.

What is the relationship between weekend visits at home and planning for discharge?
Visits to your home on weekends are encouraged because they provide opportunities to experience what it is going to be like for you and your family when you go home permanently. The weekend at home is a trial visit that can identify what went well and what was difficult so that you, your family and the treatment team can pinpoint issues that still need to be addressed before final discharge.

Throughout this process, every effort will be made to consider your individual and family needs. We are committed to making your hospital stay as comfortable and anxiety-free as possible. TOHRC would like you to know that for most people, discharge planning and transition back to the community goes very smoothly.

If you have any questions or concerns, please contact the social worker on your team. If you are calling from your room, dial 75322 for the social work secretary. If a family member is calling from outside the hospital, please call 613-737-8899, ext. 75322.

Last updated on: December 2nd, 2016