Situation
The family of a frail, elderly father contacted Patient Ombudsman with concerns about the discharge planning discussions the family had at the end of their father’s long hospital stay. The father had health challenges that were unlikely to improve and he needed a placement in a long-term care home (LTCH).
The hospital discharge planner and the Local Health Integration Network (LHIN) care coordinator told the family that an application for LTCH placement could not start while their father was in the hospital. Rather, the application process could begin only once he’d moved to a transitional care setting. It was only after the transitional care sites had responded that they could not support the father’s heavy care needs that the hospital allowed the LTCH application process to begin in the hospital. The family was concerned that finding an appropriate transitional placement for their father had already taken over a month, during which time their father could have been actively waiting for a long-term care home bed. Upon receiving the LTCH placement package, the family also received a form advising them of the hospital’s policy that failure to accept the first LTCH bed offer would result in the full hospital daily rate (per diem) to be charged.
What we did
Patient Ombudsman contacted the hospital to discuss the family’s concerns and request supporting documents. The hospital acknowledged that patients have the right to begin the LTCH application process while in hospital and they apologized if the hospital’s communication with the family was confusing. The hospital clarified that their first bed policy only applied to bed offers from the LTCHs selected by the patient and family and acknowledged that their communications did not make this clear. The hospital planned to review the form to make this clear.
Patient Ombudsman received over thirty complaints from patients and caregivers in year 3 related to confusing communications about LTCH placement from hospital. Many people expressed concerns that they had been advised that they could not initiate LTCH placement applications while in hospitals.
The “Home First” philosophy was introduced in Ontario almost a decade ago. Home First was a response to a growing awareness that LTCH placement discussions with hospital patients were often initiated before all options, including discharge home with support, had been explored. While the philosophy was intended to help address hospital capacity pressures and limited LTCH capacity, it was also firmly rooted in ensuring the best interests of patients. Home First was designed to help to avoid inappropriate or early LTCH placements and to ensure that patients and families understood that waiting for LTCH placement in hospital, in addition to placing stress on the healthcare system, was generally not good for patients’ health and well-being. The Home First approach was never intended to create a barrier when patients clearly required LTCH placement and there was no safe option for discharge from hospital.
Patient Ombudsman recognizes the significant stress that Ontario’s hospitals are experiencing balancing the need to plan safe discharges for patients ready for alternate levels of care, with the need to make room for new patients requiring acute care. However, it is important to recognize that clear, accurate communication with patients and families is critical. Unclear, inaccurate or misleading communication contributes to resistance from families, loss of trust and may ultimately lead to unnecessary delays in the discharge planning process. It is also important for hospitals and LHINs to ensure that their communications and policies comply with the law and do not inappropriately limit patients’ rights.
Tips for patients and caregivers
- Be open and responsive to engaging in discharge planning discussions, and give careful consideration to the options offered.
- Recognize that waiting in an acute care hospital for LTCH placement is not in the patient’s best interests if safe alternatives are available.
- Make as many LTCH choices as you can. You can continue to wait in a LTCH home for your other choices, and your first choice home will be given a higher priority.
- Talk to the LHIN care coordinator about what is most important to you or your loved one. They can help you create a list of homes that are most likely to meet your needs.
- If you’re confused by what you’re hearing, don’t be afraid to ask for clarification or escalate your concern to the hospital’s or LHIN’s patient relations representative.
Suggestions for HSOs
- Review your discharge planning policies and communications protocols to ensure that they are clear, compliant with the law and focused on the best interests of patients.
- Recognize that while functional assessments for LTCH placement may be more appropriately conducted in the community for some patients, not everyone can safely return home.
- Beginning the LTCH application and counselling process in hospital can ultimately speed up the discharge and placement process.
- Ensure that discharge destinations are safe, considering the patient’s condition and available supports. While LHINs, patients and families are responsible for the LTCH placement process, hospitals are responsible for safe discharges.
- Be mindful that patients and families are making emotional, life-changing decisions. They need to feel confident that they are making the best possible decisions for themselves and their loved ones.