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Spotlight 4/5

Coordinated, planned discharge from hospitals

Patients do not all follow the same path when leaving hospital care and for many, a discharge from hospital is not a simple return home. While some recover enough to go home with minimal follow-up, others may require transitional beds or rehabilitation services before returning home, or placement into a long-term care home after discharge. Each path is unique and has different criteria, timelines, and health care organizations involved.

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In 2024/25, the proportion of complaints about discharge and transitions of care was notable: 13% of hospital complaints, 13% of home and community care complaints, and 6% of long-term care home complaints.

Many of these complaints involved more than one type of health care organization. For example, many of the discharge complaints about home and community care were related to care following discharges from hospital. Complaints about discharges from hospitals made up the greatest number. Hospitals face pressure to discharge patients who no longer need acute care to make room for incoming patients. Meanwhile, patients are often faced with lengthy wait lists for long-term care homes, which are needed to support people who can no longer live safely in their own homes. In 2024, the Canadian Institute for Health Information reported that nearly one in two residents entering long-term care were admitted directly from hospital in Ontario.¹ As noted in last year’s annual report, we continue to hear concerns that the number of placements from hospitals are leading to longer wait times for people in the community. There is also increasing demand on home care services to provide care to a growing number of patients, many of whom have complex care needs. As a result, many patients with complex care needs may find it hard to find the support they need to stay at home and planning for safe, coordinated discharges can involve multiple parties.

Patient experience

The complainant contacted Patient Ombudsman with concerns about an elderly relative who had fallen at home and was taken to hospital, where it was determined that they had heart problems that needed to be managed with medication. The patient, who lived alone, was also experiencing memory problems and a decline in their ability to manage their daily care, including managing their medication. The complainant was concerned that the patient could not be safely discharged home and requested that they be assessed for long-term care home placement. The complainant was advised that the patient had the capacity to make their own decisions and wanted to go home.

Upon returning home, the patient continued to experience significant problems with their daily care and was resistant to accepting home care assistance. The complainant was also advised the high level of personal support the patient was receiving would only be available for 90 days, information that was not provided before the patient was discharged. The complainant remained concerned that the patient should have been kept in a safe environment in hospital where they felt the patient would have received a long-term care home bed much quicker than from the community.

What we did

The Early Resolution Specialist followed up with the complainant to gather further details and also contacted the patient relations representatives at the hospital and Ontario Health atHome to ask for information about their actions and decisions. The complainant reported that an application for long-term care home placement had been started when the patient came home, but they were not considered a crisis at that time. Ontario Health atHome made a commitment to fully review the case, explore the patient’s placement status, determine if additional assessments were needed, and to explore a care plan to keep the patient safe until a placement could be arranged. Upon review, it was determined that the patient was no longer capable of making care decisions and the placement priority was escalated to the crisis list.

The Early Resolution Specialist concluded that Ontario Health atHome had acted fairly in its review and follow-up actions. While the hospital did not participate fully in the resolution process, Patient Ombudsman suggested it should review and consider the quality standards developed by Health Quality Ontario (now Ontario Health) including Transitions Between Hospital and Home.

Approximately 10 years ago, Ontario introduced the “Home First” philosophy that focuses on considering whether patients can be supported to return home before other discharge options are chosen. Home First was meant to prevent premature long-term care placements and reduce capacity pressures on hospitals. It was also meant to help patients and caregivers understand that waiting in hospitals can have a negative impact on patients’ health as well as place strains on hospital capacity. This approach was not intended to impede access to long-term care from hospital or risk the safety of patients who have no safe alternative to discharge back to the community following a hospital stay.

This year, Patient Ombudsman identified 381 complaints related to discharge planning and transitional care from hospitals, 83% of which were concerned with premature and/or unsafe discharges. Many patients and their families expressed concerns over insufficient communication and a lack of clear confirmation that the appropriate home care supports would be in place at the time of discharge. Twenty per cent of complaints were concerns from patients and their families about access to long-term care homes from hospitals. Numerous complaints highlighted delays in securing suitable long-term care placements, or concerns that the placements did not fully align with the patient’s needs or preferences. In some cases, patients and their families reported feeling rushed into accepting placements without enough time to fully understand their options. Patients and caregivers also expressed concerns about rushed or uncoordinated discharge planning, with little involvement of families and caregivers, and communication that felt careless or ambiguous.

Four per cent of complaints about discharge were about chronic care co-payment fees. Despite a limited number of complaints, we saw a persistent theme in our complaints about patients and caregivers not understanding the fees or feeling they were being billed unfairly by public hospitals. Multiple complainants reported that they did not receive an explanation about the co-payment. The Ministry of Health requires hospitals to charge co-payments to patients who are seen as long-term residents of the hospital (i.e., are not expected to return to the community). This includes patients who have been designated as alternate level of care and are waiting for long-term care placement in hospital. Patient Ombudsman has carried out two investigations related to this topic within the last five years (see investigation summaries, Ensuring fair and transparent billing policies and practices, and Chronic care co-payment). In both cases, Patient Ombudsman recommended the hospitals be consistent when implementing these policies and improve communication to patients and families about fees.

Patient experience

A family member contacted Patient Ombudsman with concerns about a patient’s discharge from hospital. The patient had a history of alcohol dependence and had been admitted to hospital with chest pains and breathing difficulties. The patient stayed overnight in the emergency department and was discharged the following day, despite experiencing severe alcohol withdrawal symptoms. The family member noted that the hospital did not discuss the patient’s withdrawal symptoms, and the patient was not provided with medical advice regarding staying in hospital. The patient did not receive any medication or information on how to follow-up on the hospital visit. The patient’s mobility was severely limited at discharge and several hours after leaving the hospital, the patient experienced a medical episode. The patient was taken to a different hospital location where they were kept for approximately one week.

What we did

The Early Resolution Specialist spoke with the hospital and reviewed its policies related to discharge. The hospital had several staff review the patient’s medical file, and while this review found that the clinical decisions about the patient’s care were correct, the hospital found that communication between physicians, the patient and the family member could have been better. The hospital is working to update its discharge processes and improve communication with patients and families. Hospital leadership also engaged with local community substance use disorder organizations to learn more about local initiatives on the issue.

Ten per cent of complaints about hospital discharges were related to care in transitional care settings. Patients expressed concern about the quality of care in these settings or described being confused about fees or their care plans. Seven per cent of the total discharge-related complaints involved concerns about post-acute rehabilitation. Patients and their families expressed concerns about premature discharge from these settings, or the barriers to access because of eligibility criteria or assessments that patients would not benefit from these programs. The Ministry of Health provided additional guidance around funding for alternate health facilities, which includes transitional care spaces, noting that hospitals with transitional care units must align with Public Hospitals Act requirements.

In 2021, Patient Ombudsman completed an investigation into a complaint about the discharge process for a vulnerable patient (see the investigation summary, Breakdown in coordinated care for a vulnerable patient). We made several recommendations to the hospital and home care focused on improving care transitions and to support safe, fair and successful discharges including:

Engaging patients, decision-makers and families early and regularly in discharge planning and ensuring their preferences are heard, considered, and documented accordingly.
Providing clear, consistent written information to patients, caregivers and their families that supports decision-making and aligns with provincial legislation and policy.
Coordinating early with other care partners and ensuring vulnerable patients are identified for proper follow-up after discharge.
Facilitating the initiation of long-term care planning and placement processes in hospital settings, where appropriate.
Allowing patients and substitute decision-makers reasonable time to make informed decisions.
Ensuring processes are adaptable and reflect each patient’s unique needs, including cultural, religious and language considerations.