Ontario discharge toolkit

Home First & Health atHome

Ontario Health atHome referral worksheet: PSW, nursing, therapy, equipment, Home First.

Typical use: Hospital to home, ALC prevention, community care coordination.

Ontario’s Home First approach: people go home with support whenever it is safe, rather than waiting in hospital for long-term care. Ontario Health atHome (formerly CCAC / LHIN / HCCSS) assesses and arranges publicly funded home care. Provincial line: 1-833-515-1234. Hours and service levels vary by region — confirm, do not promise hours you cannot deliver.

Referral snapshot

Ontario Health atHome regionNamed coordinator (if already assigned)Referral sent / to be sentSent by (hospital / community / self)

What we are asking home care to look atNursing, PSW/personal support, OT, PT, speech, social work, nutrition, equipment, palliative, mental health overlay

Home First checklist

Person / SDM consents to a home-care assessment Valid OHIP and current address or “no fixed address” noted honestly There is a place that can legally and practically receive a worker Home is unsafe or no home — do not invent a Home First plan; use shelter / respite / transitional bed pathway ALC conversation happened without pressure to accept the first LTC vacancy unseen Equipment (walker, bed, commode, oxygen) source identified Public hours will not cover the first 72 hours — private / family / agency gap plan named LTC application is a parallel path, not a condition of leaving hospital

What the first visit should cover

Tasks for the first nursing / PSW / therapy visit

Who does what until the first visit actually happensIf home care has not called by this date, we call

If Home First is not possible today Transitional bed, convalescent, retirement with enhanced supports, family home, or remaining admitted — options actually available, not a wish list