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Discharging vulnerable patients safely

Complaints about premature or uncoordinated discharges from hospital to home or other care settings have consistently been in the top three complaints to Patient Ombudsman since the office opened.

In 2021/22, 11% of complaints about hospitals were about discharges and care transitions.

In addition, 19% of the complaints about home and community care were about long-term care home placement, including placements planned in hospitals. Patients and caregivers frequently report concerns about poor communication, inconsistent information, pressure to rush important decisions and coercive messages.

Patient story

A patient suffered complications from surgery in a hospital that was more than 350 kilometers away from the community where their family lived.

While in hospital, the patient was assessed to require long-term care home placement and the family wanted them to be placed in a long-term care home close to family so that they could support the patient’s ongoing care needs.

A family member told Patient Ombudsman that the patient was forced to accept a placement in the community where the hospital was located. The patient had been waiting for more than a year to be transferred to a long-term care home closer to family.

The complainant was referred to the home and community care support services organizations in both communities to attempt to resolve their concerns and was advised that they could reconnect with Patient Ombudsman after working with home and community care.

For many years, hospitals have been experiencing capacity pressures and challenges with managing the discharge of patients who require ongoing care but no longer require acute hospital care.

Discharge planning for patients who require long-term care and cannot go home safely to wait for a bed can pose a particular challenge given the long waitlists for long-term care homes. It is widely accepted that acute care hospitals are not optimal settings for elderly patients waiting for long-term care. In addition to reducing acute care capacity, patients waiting for long-term care are at risk for hospital-acquired infections and hospitals are not equipped to meet the social, recreational and physical activity needs of frail seniors.

The COVID-19 pandemic has added to these challenges. Human resource shortages, outbreaks and higher demand have increased pressures on hospitals to discharge patients as quickly as possible. At the same time, the massive outbreaks and high rates of resident death in long-term care homes early in the pandemic have decreased confidence in the long-term care home system for many and have made families more cautious about their selection of homes.

The pandemic has also highlighted the important role families and friends play in supporting patients in hospitals and residents in long-term care. As highlighted in Patient Ombudsman’s special reports on COVID-19, restrictions on visitation and the resulting isolation and lack of stimulation have had an impact on the health and well-being of patients and residents. Family and friends of patients and residents have shared the trauma of not being present to support loved ones or lost opportunities to say goodbye before a loved one dies. The ability to visit is a key consideration in families’ selection of care settings, including long-term care homes.

Patient story

A patient in their late 90s was admitted to the hospital with a serious infection. After several weeks in hospital, the family was told the patient was ready for discharge. The family was concerned that the patient was still very frail, needed constant care and the patient’s home was not suitable to support their care. The unit manager informed a family member that it wasn’t ‘their problem’ and referred the family member to patient relations. The family member contacted patient relations and other members of the care team, and a safe discharge plan was developed. An assessment for admission to a retirement home was arranged for the following week with the goal of transferring the patient two days later.

Three days before the planned assessment, the family member found a letter in the patient’s room indicating that they would be discharged the next day, and if the patient didn’t leave the hospital, they would be charged the full daily fee for their remaining time in the hospital.

When the family questioned the decision, they were told to arrange for a hotel room until the patient could be moved to the retirement home. The case is still open with Patient Ombudsman.

Our recommendations

To ensure safe, fair and successful discharges and care transitions for patients, Patient Ombudsman suggest the following considerations:

Engage patients, substitute decision-makers and family members early and often in discharge planning discussions. Ensure they have the opportunity to express their views and preferences, and that their views and preferences are considered and documented.
Provide clear and consistent information, including in writing, to help inform decisions and ensure the information provided is aligned with provincial legislation, regulation and policy.
Give patients and substitute decision-makers a reasonable time frame to make decisions.
Ensure processes are flexible and consider patients’ individual needs and circumstances, including their social, cultural, and religious needs and any needs for special accommodation, such as the need for interpreter services.
Recognize the stress and life-changing nature of long-term care home placement decisions and ensure that patients and their families are treated with courtesy and respect.
Ensure patients and substitute decision-makers know who to contact if they have questions or disagree with the proposed options or decisions.

Patient story

The complainant’s parent fell at home following a stroke and was hospitalized for several months. It was quickly determined that they would be unable to return home. The family was informed on multiple occasions that they could not apply for long-term care home placement while in hospital.

How did we resolve this?