What post-discharge home care involves
The first days and weeks at home after a hospital stay are the period when the right support makes the most difference — and when the absence of it carries the most risk. A well-structured discharge care plan addresses both the practical and clinical needs of the transition, reducing the likelihood of a return to hospital and giving families confidence that the person is safe at home.
Here is what Arcadia's post-discharge support typically includes:
Rapid care arrangement
Care in place within 24–48 hours of contact in most cases. We move at the pace the discharge requires.
Personal care and hygiene
Assistance with bathing, dressing, and grooming — the daily activities most often unsafe or exhausting in the first days and weeks after hospital.
Medication management
Consistent prompting at the right times, monitoring for side effects, and flagging concerns to family or the medical team before they become problems.
Mobility and fall prevention
Safe movement support, transfer assistance, and fall risk reduction — particularly important in the first week when fatigue and deconditioning are highest.
Wound care monitoring
Observing surgical sites or wounds for signs of infection and communicating changes promptly to family or the care team.
Meal preparation and nutrition
Preparing appropriate meals and monitoring intake — recovery depends on nutrition, and many patients leave hospital with reduced appetite or specific dietary requirements.
Transportation to follow-up appointments
Accompanying the person to follow-up appointments — often the first practical challenge after discharge and one of the most important for continuity of care.
Overnight and 24-hour coverage
When continuous supervision is needed — in the first nights home, or for clients with complex conditions — Arcadia can provide overnight and around-the-clock care.
Complex discharge situations — when underlying conditions are involved
Post-discharge care for someone with an underlying condition requires more than standard home care. A patient being discharged with dementia, acquired brain injury, or a palliative diagnosis has clinical needs that go significantly beyond what a general PSW or companion can manage. Arcadia's specialization in these conditions means that complex discharge cases are handled with the clinical depth they require.
We specialize in complex discharge cases involving
Discharge happening in the next 24–48 hours?
Call us now. We will ask the right questions, move quickly, and have a care plan in place before your loved one arrives home.
(844) 977-0050Book a Free ConsultationHow Arcadia arranges post-discharge care
1
First call — gather the essentials
We need the basics: who is being discharged, why they were admitted, what support they will need at home, and when they are leaving. The more clinical detail you can share, the better the plan we can build. If a discharge planner or social worker is involved, we can coordinate directly with them.
2
Care plan built around the discharge situation
We build a care plan based on the specific needs of the discharge — not a template. For straightforward post-surgical recovery, that may mean daily personal care and medication reminders. For a complex discharge involving dementia or ABI, it means a clinically informed plan that accounts for the full picture.
3
Caregiver matched and briefed before arrival
We select a caregiver appropriate to the situation, brief them thoroughly on the person's needs and history, and ensure they are prepared for what they will encounter at home — not discovering it for the first time on arrival.
4
Care begins — with close monitoring in the first week
The first week is the most vulnerable period. We check in with both the family and the caregiver frequently and respond quickly if something is not right. Our goal is that no gap in care goes unaddressed for longer than necessary.
5
Ongoing adjustment as recovery progresses
Post-discharge care needs change over time. As the person recovers, the level of support required typically decreases. We adjust the plan accordingly — and we communicate honestly when things are not progressing as expected.
Understanding publicly funded vs private post-discharge care
Ontario Health atHome coordinates publicly funded home care following hospital discharge — including nursing, PSW hours, and therapy services. For most families, this is a meaningful foundation. But the hours allocated are often limited, and the first funded visit may not happen immediately after discharge.
Private home care fills those gaps — in the first days when publicly funded care has not yet started, on days and at hours when funded support is not scheduled, and when the overall level of support provided does not match what safe recovery actually requires.
Arcadia works alongside Ontario Health atHome across Toronto, North York, Scarborough, Etobicoke, Markham, Richmond Hill, and Mississauga. Our team can help families understand what public funding may be available and what private support may be needed to fill the gap.
Frequently Asked Questions
Questions families and professionals ask about discharge support
How quickly can Arcadia arrange care after a hospital discharge?
In most cases, within 24 to 48 hours of a first conversation. We understand that hospital discharges move quickly and that families often have very little time to plan. If the situation is urgent, call us directly — we will do our best to move at the pace the discharge requires.
What information does Arcadia need to arrange post-discharge care?
The basics: the person's name and address, the reason for hospitalization and any relevant diagnoses, what support they will need at home, their expected discharge date, and a contact for the family or discharge team. If there are specific clinical considerations — wound care requirements, mobility restrictions, medication changes — we need to know those too. The more context we have, the better the care plan we can build.
Will Ontario Health atHome provide support after discharge? Do we still need private care?
Ontario Health atHome coordinates publicly funded home care following discharge, but the hours allocated are often limited and may not begin immediately. Many families use private home care to fill the gap between discharge and the start of publicly funded services, or to supplement the hours that funding provides. Arcadia works alongside Ontario Health atHome — not instead of it — and can help families understand what they are entitled to.
Can Arcadia support someone coming home with complex needs — dementia, ABI, or palliative?
Yes. Post-discharge support for clients with complex underlying conditions requires more than standard home care. Arcadia specializes in dementia, acquired brain injury, and palliative care, and our discharge support for these clients is built around the specific clinical requirements of each condition. We do not treat a dementia-complicated discharge the same as a routine post-surgical recovery.
What is the risk of not having support in place at discharge?
The first days and weeks after hospital discharge are often the period when risk is highest in a person's recovery. Gaps in supervision, missed medications, falls, inadequate nutrition, and undetected infections are among the most common contributors to readmission. Having the right support in place from day one — even for a limited number of hours — can help reduce those risks.
How does Arcadia coordinate with the hospital discharge team?
Discharge planners and social workers can refer directly to Arcadia using our professional referral form or by phone. We respond promptly, gather the clinical information we need, and communicate back to the discharge team about the plan in place. We also coordinate with Ontario Health atHome and any other providers involved in the person's care.