After Hospital Consult

Logo for an home care after discharge from hospital or after surgery in Edmonton, Alberta
After discharge telephone follow-up with nursing care - Home Care after Discharge from Hospital in Edmonton, Alberta
On-call nursing care to enhance recovery after discharge from hospital.
Are you thriving after discharge from hospital?
If you require immediate medical attention, please call 9 1 1 or go to your nearest emergency department.

Many families have questions about their care after discharge from hospital.

That is why we provide nursing services to Edmonton area residents recovering from an acute illness or injury in the community.

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.

We also know Edmonton area families benefit from expert care during these transitions.

Our approach:

  • Comprehensively assess symptoms
  • Stabilize disease conditions & home safety concerns
  • Coordinate referrals & follow-up
  • Build an expert team to support the patient

We are here and ready to help in the community.

Everything we do is focused on helping your family achieve a new normal after hospital discharge. We review your provincial health records, collaborate with your family doctor, provide nursing care, and coordinate referrals when required.

“It was a blessing and a curse. I remember his primary nurses continuously 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 supports are important. And, caregiver distress is often prevented when health professionals proactively stabilize acute symptoms with early assessment and restorative nursing care.

We partner with your family to provide care in the community.

We continue to monitor health conditions. Over the long term, we try to improve things like balance and nutrition after discharge from hospital. For example, you might require on-call nursing care. We provide patients and caregivers with peace of mind that they are connected to expert caregivers any day of the week.

Community Supports After Surgery

Many people require additional supports after surgery. While government-funded care often supports basic nursing needs, families may be anxious to take on the work of providing care.

Daily care needs after surgery need to be manageable for both patients and their caregivers.

Our community-based team supports recovery after surgery. We do this by proactively managing post-operative symptoms and functional limitations. This creates opportunities to build strength after surgery.

The community nursing care provided after surgery is highly flexible, built around short-term and specialized care options. This includes:

  • Referrals for daily care
  • Health monitoring
  • Medication assistance
  • Wound & drain care
  • Post-surgical assessments
  • Home exercise plans
  • Nutrition support

We’ve also adopted an “assess, treat and refer” approach to ensure care is matched to your needs after surgery

Recover at Home after Surgery

It’s hard to feel better after surgery until your symptoms are well-managed. That is why we routinely assess post-surgical pain, fatigue, nausea and constipation in the community.

Our community nursing professionals also manage the underlying causes of symptoms to prevent post-surgical complications like infection, falls and malnutrition.

Once your post-surgical symptoms are stabilized, our team can safely introduce new therapies (like exercise) in the community.

This approach helps patients regain strength and function after surgery.

We Want to Talk

Some symptoms (like fatigue, nausea and pain) also affect how we feel after surgery.

Families may notice that something has changed.

That’s why we also offer psychological supports as part of our community care program. Our staff is here and ready to help clients (and their families) feel more confident so they can safely tackle all types of challenges in the community.

Nursing Care After Discharge from Hospital

Our after hospital assessment and consultation can include:

  • Complex care management
  • Symptom coaching
  • Wound, ostomy and drain care
  • Referral and care protocols
  • Meals & dietary assistance
  • Help with housekeeping
  • Help with daily care
  • On-call nursing care
  • Home safety adaptations
  • Psychological support
  • Case conferencing with physician
  • Care coordination & referrals
On the road to recovery after your hospital stay?

* 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 home care provides access to provincially-funded home care after hospitalization in Edmonton, Alberta.

AHS Continuing Care Access manages access to publicly-funded home care in the Edmonton area.

Health Link Alberta (811) provides free health advice to all Alberta residents, including connection to home health care and other home care services.

Health Link Alberta (811) provides free navigation, health advice and referral to provincial health services.

Brain Care Centre - home care nursing and support at after discharge from hospital.

Brain Care Centre provides services and social supports to Edmonton residents with acquired brain injuries.

* provides links to these external providers to help Edmonton residents self-refer to the best possible services for their health condition.