Ontario discharge toolkit

Transition Plan

Patient-oriented discharge summary: where I am going, who is involved, follow-up, and what to watch for.

Typical use: Hospital, withdrawal management, inpatient MH, residential treatment, crisis bed.

Write in everyday language. The person leaving care should be able to read this without a glossary. Leave identifiers off shared printers.

Who this plan is for

Name the person usesOnly if they want it on the printed pagePlan dateLeaving fromED, unit, WM, residential, crisis bed…

Going toAddress or program name (optional)

What a good next week looks like — in their words

Care team they can actually reach

Primary care / NPNumberMental health or addiction workerNumberOntario Health atHome coordinatorNumberProvincial intake 1-833-515-1234 if unknownPharmacyNumber

What was treated / what continues Issues addressed this stayIssues still open after todayWarning signs that mean I should get help todayBreathing, chest pain, suicidal intent with plan, withdrawal seizures, inability to keep fluids down…

Follow-up already booked

Appointments

Still needs booking (who will book it, by when)

Practical landing

OHIP card in hand Discharge prescriptions filled or a plan to fill today Ride / transit / ambulance transfer arranged Keys, lock, or shelter bed confirmed for tonight Food for the next 24 hours Working phone or a way to be reached Consent noted to share this page with a named support person

Gaps we could not close before the door — and the workaround