Coming Home From Hospital — Understanding the Home Care Plan
Coming home with Home & Community Care involved?
Leaving hospital can feel like a big transition. You may be hearing about Home & Community Care, a referral, equipment, a Case Manager, or services that are expected after you get home.
You do not need to understand the whole healthcare system.
What matters is knowing:
- what has actually been arranged;
- what is still pending;
- when the first expected service or visit is;
- who is responsible for arranging important pieces; and
- who you should contact if something is unclear or does not happen as expected.
This page will help you know what to ask before you leave hospital.
Coming home soon? Start with the questions to ask before you leave.
See the Questions to AskKnow the Plan Before You Leave
Before you go home, try to understand the Home & Community Care part of your transition plan.
Different people may be involved in helping you prepare to leave hospital. You do not need to figure out everyone's job.
Instead, start with a few practical questions:
If something does not make sense, ask for it to be explained again.
You can also involve a trusted family member, caregiver or support person if that would help you understand and remember the plan.
These are practical preparation suggestions from KYR. They are not mandatory Alberta discharge requirements.
Who Is Coordinating the Transition?
Depending on your situation, different people may be involved in planning your transition home.
This could include members of your hospital healthcare team, a discharge or transition professional, Home & Community Care, or a Case Manager where applicable.
There is not one person who necessarily handles every part of every transition.
So rather than trying to understand the whole system, ask:
If Home & Community Care will be involved, also ask:
You can also ask:
Write down the name or contact information you are given if that will help you later.
What Home & Community Care Has Actually Been Arranged?
This is important.
Something may have been discussed, requested or referred without yet being confirmed.
You do not need to learn special system terminology. You simply need to find out what you should actually expect.
Try asking:
A referral or request does not by itself guarantee that a particular service, amount of funding or number of care hours will be provided.
The goal here is to understand your own confirmed transition plan as clearly as possible.
When Is the First Expected Visit or Service?
KYR did not identify one universal timeframe that applies to every person for when Home & Community Care begins after leaving hospital. Your expected timing depends on your own transition plan.
That makes this a particularly important question:
If you are unsure, also ask:
Do not assume someone will arrive as soon as you get home unless that is what your own transition plan says.
Knowing the expected timing can help you and your family understand what is supposed to happen next.
What Happens Between Arriving Home and the First Service?
There may be time between arriving home and the first expected Home & Community Care visit or service.
Before you leave hospital, ask what the plan is for that period.
KYR does not provide clinical discharge instructions.
This page is not telling you or your family how to perform nursing care, medical procedures or other professional care at home.
If you do not understand clinical instructions you have been given, ask the appropriate member of your healthcare team to explain them.
Do not assume that a family member is automatically responsible for providing professional care while you wait for an expected service.
Who Is Responsible for Arranging Each Piece?
During a hospital-to-home transition, different people or programs may be responsible for different parts of the plan.
That means statements such as:
or:
may be too broad.
Instead, for anything important, ask two questions:
You can use these questions for services, referrals, equipment or another important part of your Home & Community Care transition.
You do not need to know the whole organizational structure.
You need to know who is responsible for the next step in your situation.
Equipment and Preparing the Home
This section applies only if equipment is part of your transition.
Not everyone coming home from hospital needs equipment.
If equipment is expected, try to understand what has actually been arranged before you leave.
What about AADL?
The Alberta Aids to Daily Living (AADL) program may be relevant for some equipment and supplies.
AADL has its own assessment, authorization and eligibility requirements. Mentioning AADL does not mean that you qualify or that a particular item will be funded.
If AADL may be involved, ask about the assessment and authorization process before buying equipment on the assumption that AADL will reimburse you.
Before You Leave: Questions to Ask
You do not have to ask every question below.
These are KYR practical preparation questions, not a mandatory Alberta hospital-discharge checklist.
Choose the questions that fit your situation.
About the transition
- Who is coordinating or helping with the plan for coming home?
- What Home & Community Care has actually been arranged?
- Has the referral or handoff happened?
- Is anything still pending?
- Who is our Home & Community Care contact?
About timing
- When is the first expected service or visit?
- What is supposed to happen between arriving home and that first service?
- Is there anything we are expected to do?
About responsibility
- Who is responsible for arranging each important piece?
- Who should we contact if something expected does not happen?
If equipment is expected
- What equipment is expected?
- Has it been assessed or arranged?
- When should it arrive?
- Who is responsible for arranging it?
- Who should we contact if it has not arrived?
A simple script
If you are not sure how to start the conversation, you could say:
“We want to make sure we understand the Home & Community Care plan before we go home. Could you please tell us what has actually been arranged, what is still pending, and who we should contact if something does not happen as expected?”
What If Something Expected Does Not Happen?
If something about the immediate hospital-to-home transition is unclear, pending, delayed or has not happened as expected, start by trying to clarify the transition.
If you are still in hospital
Ask the healthcare team or the person helping with your discharge or transition:
- What is supposed to happen?
- Is it confirmed or still pending?
- Who is responsible for arranging it?
- Who should we contact after we leave?
If you are already home
If you were given a specific transition contact, Home & Community Care contact, Case Manager contact where applicable, or another relevant contact for the transition, start with that contact.
Explain what you expected to happen and ask whether the arrangement has changed or whether something is still pending.
If you do not know whom to contact, use the current Continuing Care Access / 811 pathway to ask where to begin.
This is a navigation starting point, not a formal complaint or escalation pathway.
Call 811This is different from an ongoing Home Care concern
Core 2 is about the immediate handoff from hospital to home.
If Home & Community Care is already underway and you have an ongoing problem with service delivery, follow-up, quality or another concern, that is a different situation.
KYR addresses that separately in:
When Home Care Is Not Working
ግብዓት እየተዘጋጀ ነውWhat Can I Do Next?
You do not need to remember everything about the healthcare system before you leave hospital.
Focus on understanding the next few steps.
Before you go home, try to know:
It can help to write down the answers and keep the relevant contact information somewhere easy to find.
If you would like a trusted family member, caregiver or support person involved in the conversation, ask whether they can participate.
If you need interpretation support, you can ask about that too.
Official AHS Resource: My Next Steps
My Next Steps — Getting Ready to Leave the Hospital
Alberta Health Services has a broader hospital-discharge preparation resource.
It can help patients and families think through questions and prepare for leaving hospital.
KYR Core 2 has a narrower purpose: helping you understand the Home & Community Care part of coming home.
The AHS resource can be used alongside this page for broader discharge preparation.
Open AHS My Next Stepsአስፈላጊ የትምህርት ማስታወቂያ
Knowing Your Rights (KYR) provides general educational information to help Alberta seniors, caregivers and families understand and navigate Home & Community Care.
KYR does not assess your healthcare needs, determine eligibility, create your care plan or decide what services, equipment, funding or care hours you will receive.
This page does not replace advice, instructions or decisions from your hospital healthcare team, Home & Community Care team, Case Manager or other appropriate healthcare professionals.
The practical questions on this page are KYR preparation suggestions. They are not mandatory Alberta discharge requirements and do not guarantee that a particular service, referral, piece of equipment, funding or outcome will be provided.
If you do not understand your clinical discharge instructions, ask the appropriate healthcare professional to explain them.
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