Going home: Plan your transition before being discharged

The Bottom Line

  • Older adults often experienced an insecure or unsafe hospital-to-home transition, and had difficulty settling into their new situation at home.
  • Quality transitions from hospital to home result in a number of positive outcomes (including reduced length of stay at the hospital; reduced hospital readmissions; reduced admission to long-term care homes; and better health outcomes and quality of life).
  • Make sure that you (or your caregiver) play an active role in planning your transition back home. 

Going home from the hospital can be both an exciting and stressful time for patients and their caregivers. They are leaving their hospital routines and their hospital-based care team (which may include doctors, nurses, physiotherapists, mental health workers, dietitians, and volunteers). They will need to establish new routines to manage their own health and care back home. This may include using a new medication or treatment, or working with a different care team.(1)

A recent systematic review examined older adults’ experiences of adapting to daily life after going back home from hospital.(2) The review revealed that older adults often experienced an insecure or unsafe transition (for example, experiencing a rushed discharge, being confused about medication and how to take it, not understanding the information provided to them, lacking coordination and communication between providers, conflicting opinions between providers), and had difficulty settling into their new situation at home (for example, losing independence, home not being prepared, having problems performing daily activities, feeling lonely and isolated).

Hospital-to-home transitions can be particularly stressful for older adults with complex health and social needs (and for their caregivers too). It is increasingly common for older adults to have multiple chronic conditions. Many are also living with a mental health conditions (anxiety, depression, and Alzheimer’s and other dementias). These older adults are at increased risk for poor quality of life and poor health outcomes, particularly when they are transitioning from hospital to home.(3) They will typically receive fragmented care from multiple care providers who often lack a common system for coordination and communication.(4; 5)

In addition, many older adults with complex health needs live in complex social circumstances. They may be financially insecure, lonely, geographically isolated, in inadequate and unaffordable housing, have limited ability to use health information, and may be are unaware of care and other supportive services in their community.(6) All these factors may negatively affect their transition from hospital-to-home.

Carefully planning and supporting hospital-to-home transitions is so important. Quality transitions from hospital to home result in a number of positive outcomes, including:
- reduced length of stay at the hospital;(7)
- reduced hospital readmissions;(7-9)
- increased use of primary-care services that could help to prevent health problems;(8)
- reduced use of unnecessary home-care services;(8)
- reduced admission to long-term care homes;(10) and
- better health outcomes and quality of life.(11)

However, poorly planned and supported transitions pose serious safety risks to older adults, lead to complications and hospital readmissions, and put an added strain on older adults, their caregivers and the entire health system.(12; 13)

You are part of the care team, join the planning!

Make sure that you (or your caregiver) play an active role in planning your transition back home. Concrete tools could help you engage in conversations with the hospital-based care team (for example, the Patient Conversation Guide being developed by Health Quality Ontario). Hospital-based care team are increasingly using tools to provide clear instructions to know how to manage at home once discharged (for example, the Patient-Oriented Discharge Summary used in 27 hospitals across Ontario).

The content of this blog post is based on a citizen brief prepared by the McMaster Health Forum: Gauvin FP, Gannan R, Heald-Taylor G, Markle-Reid M, McAiney C, Moat KA, Lavis JN. Citizen brief: Engaging older adults with complex health and social needs, and their caregivers, to improve hospital-to-home transitions in Ontario. Hamilton, Canada: McMaster Health Forum, 15 November 2019.


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Author Details


  1. Health Quality Ontario. Going home from the hospital: Questions to ask your care team as you get ready to leave the hospital. Toronto, Canada: Health Quality Ontario; 2019.
  2. Hestevik CH, Molin M, Debesay J, Bergland A, Bye A. Older persons' experiences of adapting to daily life at home after hospital discharge: A qualitative metasummary. BMC Health Services Research 2019;19(1): 224.
  3. Marengoni A, Angleman S, Melis R, et al. Aging with multimorbidity: A systematic review of the literature. Ageing Research Reviews 2011;10(4): 430-9.
  4. Ganann R, McAiney C, Johnson W. Engaging older adults as partners in transitional care research. Canadian Medical Association Journal 2018;190(Suppl): S40-S41.
  5. Fortin M, Lapointe L, Hudon C, Vanasse A. Multimorbidity is common to family practice: is it commonly researched? Canadian Family Physician 2005;51: 244-5.
  6. Health Quality Ontario. Transitions between hospital and home. Toronto, Canada: Health Quality Ontario; 2019. https://www.hqontario.ca/Quality-Improvement/Quality-Improvement-in-Action/Health-Links/Health-Links-Resources/Transitions-between-Hospital-and-Home (accessed 8 October 2019).
  7. Shepperd S, Lannin N, Clemson L, McCluskey A, Cameron I, Barras S. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2013(1469-493X (Electronic)).
  8. Weeks LE, Macdonald M, Martin-Misener R, et al. The impact of transitional care programs on health services utilization in community-dwelling older adults: A systematic review. JBI Database of Systematic Reviews and Implementation Reports 2018;16(2): 345-384.
  9. Allen J, Hutchinson AM, Brown R, Livingston PM. Quality care outcomes following transitional care interventions for older people from hospital to home: A systematic review. BMC Health Services Research 2014;14: 346.
  10. Hyde CJ, Robert IE, Sinclair AJ. The effects of supporting discharge from hospital to home in older people. Age and Ageing 2000;29(3): 271-9.
  11. Registered Nurses’ Association of Ontario. Care transitions. Toronto, Canada: Registered Nurses’ Association of Ontario; 2014.
  12. Tepper J, Kiran T. Transitions in care: Telling the patient story. Toronto: Canada: Health Quality Ontario; 2018. https://www.hqontario.ca/Blog/patient-engagement/transitions-in-care-telling-the-patient-story (accessed 20 June 2019).
  13. Health Quality Ontario. Transitions from hospital to home: Concept mapping training. Toronto: Canada: Health Quality Ontario; 2018. https://www.youtube.com/watch?v=OFSIfRFafm4&feature=youtu.be (accessed 20 June 2019).



DISCLAIMER: These summaries are provided for informational purposes only. They are not a substitute for advice from your own health care professional. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the McMaster Optimal Aging Portal (info@mcmasteroptimalaging.org).

Many of our Blog Posts were written before the COVID-19 pandemic and thus do not necessarily reflect the latest public health recommendations. While the content of new and old blogs identify activities that support optimal aging, it is important to defer to the most current public health recommendations. Some of the activities suggested within these blogs may need to be modified or avoided altogether to comply with changing public health recommendations. To view the latest updates from the Public Health Agency of Canada, please visit their website.