Hospital discharge is a critical transition

Discharge from hospital is one of the most common points at which home care needs increase. People often leave hospital with more complex needs than when they arrived — recovering from surgery, managing new medications, or dealing with post-event limitations.

The challenge is that this transition can be abrupt, and not all families are well-prepared for what comes next.

How discharge planning works

Most Quebec hospitals have a social worker or discharge planner who coordinates post-discharge care. Their role is to:

• Identify care needs before discharge
• Refer to CLSC home care services
• Arrange any equipment or supplies needed at home
• Communicate the discharge summary to the CLSC and family physician

Ask for this person by name before discharge if you haven't been contacted. Don't wait until the day of discharge to start this conversation — raise it as soon as a discharge date is discussed.

What the CLSC should do after a hospital referral

When the hospital refers to the CLSC, the CLSC should contact the family within a few days of discharge to arrange an assessment or initiate services. Post-hospitalization referrals are typically prioritized over routine intake.

What to do if support is not in place at discharge

Sometimes people are discharged with services not yet confirmed or with a gap before services begin. In that situation:

• Call your local CLSC immediately and explain the person has just been discharged from hospital and needs urgent home care
• Request a priority assessment — use the word "urgent" and mention the discharge
• Contact Info-Santé (8-1-1) for immediate guidance on managing care needs at home until services begin
• Bridge the gap privately if needed — a private agency can provide short-term home care while waiting

Key documents to request at discharge

Ask the hospital team for:

• The discharge summary
• Updated medication list
• Any nursing care instructions (wound care, physiotherapy protocols)
• The name of the discharge planner and the CLSC they referred to

Keep these documents — they become essential for the CLSC's assessment and for any future reassessments. See Hospital discharge summaries for more detail.