Transitional home care to support your recovery after discharge from hospital.
Are you worried about returning home after hospital?
We’re here and ready to help!
It is hard to know what is ‘normal’ after discharge from the hospital. We prevent caregiver burnout by helping families manage unexpected events after discharge.
Our approach:
- Assess and treat acute conditions.
- Address home safety concerns.
- Tackle functional syndromes & symptom distress.
- Refer to relevant programs and services.
- Build a system of care around you, the patient and family.
Everything we do is focused on helping you return to a new normal after discharge. We review your provincial health records, collaborate with your family doctor, provide on-demand nursing care, and coordinate referrals when required.
“It was a blessing and a curse. I remember his primary nurses constantly saying I know you can do it, but you can’t do it every single day and every single night. You need to have some sort of break.”
— family’s experience providing care after discharge from hospital
Caregiver distress can be prevented by stabilizing functional syndromes and disease impacts at home.
That’s why we closely monitor health conditions as a routine part of our care. Over the long term, we try to improve things like balance and nutrition at home. For example, you might require on-call nursing care. We provide patients with peace of mind, with access to expert caregivers any day of the week.
Our after hospital consultation can include:
- Care navigation and advocacy
- Functional rehabilitation
- Wound, ostomy and drain care
- Meals & dietary assistance
- Help with housekeeping
- Help with daily care
- Home safety adaptations
- Psychological support
- On-call care
- Case conferencing with physician
- Care coordination & referrals
* See Schedule of Health Service Fees for an itemized list of nursing fees
Summary for Health Professionals
| Our after hospital care program… |
|---|
| Manages complex conditions using an assess, treat and refer approach. |
| Facilitates access to a variety of care options after discharge from hospital or surgery. |
| Identifies a person’s goals and priorities for health recovery. |
| Helps stabilize symptoms in the community. |
| Aims to improve home safety. |
Our ‘after hospital care’ program provides sub-acute/restorative nursing care in tandem with post-surgical nursing care, chronic disease management, symptom management, psychological counselling, functional nutrition & exercise coaching. We create new patterns of living within the community, aiming to prevent hospital readmission while simultaneously reducing frailty and the burden of daily symptoms.
Limitations & Exclusions
We do not provide emergency care. If your patient is experiencing any sudden or unexpected change in health status, please do not refer them to a community-based nursing service. Emergency Medical Services (EMS) should be activated for medical emergencies, or the patient should be immediately referred to their nearest Emergency Department.
Why choose this program?
- We go beyond providing community supports to stabilize underlying disease conditions and symptoms that can destabilize recovery in the community.
- We have adopted a unique model of care to understand an individual’s lived experience and identify what symptoms may interfere with post-hospital recovery, using an evidence-based approach.
- We work closely with physicians, allied health professionals and other health-care services to mobilize the best possible team to improve care outcomes (like strength and balance) in the community.
Have questions?
Why not call a nurse to discuss how you are living with health concerns? Get in touch when it’s convenient for you, and let us look into a range of care options for your particular health question.
Other care options are also available in the Edmonton area.
There are many other community supports available to Edmonton residents. In many cases, other services could be a better fit for your health needs. Feel free to call us to help navigate these care decisions.
Alternate care options include: *
AHS Continuing Care Access manages access to publicly-funded home care in the Edmonton area.
Health Link Alberta (811) provides free navigation, health advice and referral to provincial health services.
Brain Care Centre provides services and social supports to Edmonton residents with acquired brain injuries.
* ConsortiaCare.ca provides links to these external providers to help Edmonton residents self-refer to the best possible services for their health condition.