How information moves between hospital and home care

Your dad is home by mid-afternoon, his coat still on, a carrier bag of hospital letters on the hall chair. The first home care visit is booked for tomorrow morning, and nobody in the family is quite sure what the carer will have been told. This article sets out what published guidance in a few places says about how information passes between a hospital and the people who give care at home, and what you and your parent can ask. It will not say what to expect for your parent's health after a hospital stay, and it is information, not medical advice. The guidance here comes from England, from Ontario in Canada and from the United States, each speaking for its own place, and arrangements where your parent lives may differ.

Who the guidance says should hear

In Ontario, Canada, Ontario Health's quality standard on moving between hospital and home sets out that a person's written transition plan is meant to be shared with the health professional who gives their primary care and with their home and community care providers. NICE's guidance for England on moving between hospital and home says the discharge plan should be given to the person and to everyone involved in their ongoing care and support, family and unpaid carers among them if the person agrees.

The same NICE guidance for England describes one practitioner, the one coordinating the discharge, acting as the central point of contact for the person and their family while it is planned, with contact details for after the person is home included in the discharge plan. That is a description of guidance in England, not a promise that such a role exists everywhere, or goes by the same name.

Your parent's part in it

NICE's guidance for England says everyone receiving care should be seen as an individual and an equal partner, able to make choices about their own care. Ontario Health's guide for people leaving hospital in Ontario, Canada, says the person should be involved in every decision about going home, and that family and care partners can take part in those decisions if the person wants them to.

On the family's side, NICE's guidance for England says that, with the person's agreement, the views and wishes of their family and unpaid carers should be included in planning the discharge. In Ontario, Canada, the same Ontario Health guide says that if the person agrees, family and care partners should also receive a written copy of the transition plan.

In the guidance here, the family's place in a hospital discharge comes through your parent, not around them.

What goes home with the person

NICE's information for the public in England says a person going home from hospital should be given, on the day they leave, a summary of what they talked about needing at home, including the names of everyone who will give them health and social care support there. Where home and community care services are needed, Ontario Health's quality standard for Ontario, Canada, says they are meant to be arranged before the person leaves hospital and to be in place when they arrive home.

What a home care service itself can cover is set out in What help at home can include.

Questions you and your parent can ask

NICE's information for the public in England suggests questions a person, or their family or unpaid carer, might want to ask before going home, such as who the main point of contact is, and who will make sure the family and unpaid carer have the information and support they need for the move home. For people leaving hospital in Ontario, Canada, Ontario Health's guide suggests asking the hospital team who to contact with questions about the plan once the person is home. A discharge planning checklist from the US Centers for Medicare & Medicaid Services suggests that people leaving hospital, and the family or friends helping them, write down the names and phone numbers of people to call with questions or concerns, and ask where their care will come from afterwards.

Who will pass the plan, and any later change to it, to the home care provider is a fair question for the hospital team and for the provider, asked with your parent.

Ontario Health, in its going-home guide for Ontario, Canada, says a health professional should talk with the person before they leave about any changes made to their medicines and why. Who to speak to about any such change is a question for the care team.

Keeping those names and numbers somewhere you and your parent can both find them is part of Getting organized: documents, contacts, and access.

Questions about your parent's health after a hospital stay, and about any change to their care, are worth bringing to their doctor or care team, and your parent decides which of them to raise first. Questions about visit times, and who the carer will be, sit with the home care provider.