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Your care plan after leaving the hospital

  • Transition conference with your health care team

    Transition conference goals

    Your health care team will work with you to understand the challenges you have after your hospital stay. This will help your team work toward a plan to make sure you have the right care and support to help manage your health after you leave the hospital.

    You and your family member or caregiver, along with members of your health care team will meet to talk about your care. This is called a transition conference.

    The goals of the transition conference are to help:

    • prevent an avoidable return to the hospital
    • you and your family member or caregiver get the right care and support when your hospital stay ends and you transition to "what's next."

    Who will attend the transition conference

    You and your family member or caregiver will meet with the doctor taking care of you in the hospital, and the social worker or case manager.

    Other members of your health care team may also be invited.

    A caregiver is a family member or someone who helps you with activities such as:

    • getting groceries and making meals
    • walking or providing rides
    • helping with chores, laundry or bathing
    • helping with medicines
    • helping with doctor appointments, legal matters or banking
    • providing companionship or supervision

    If there are other people you would like to attend the transition conference, tell the social worker.

    The transition conference may take place in person, over the phone or by video conference.

    What you can expect during the transition conference

    Together, you and your family member or caregiver will talk with your health care team about:

    • your goal(s) when you leave the hospital
    • what might keep you from meeting your goals
    • your health care team's goals for your health
    • your care options after your hospital stay
    • what support you will need out of the hospital and how this support is provided. Your family member or caregiver will be included to make sure he or she can provide the support you need.

    Ask that members of your health care team answer all of your questions and concerns using plain language.

    After the transition conference, a summary of the meeting will be put in your medical record. You will receive a copy.

    Your health care team will work closely with you and your family member or caregiver to coordinate your transition from the hospital.

    What to think about before your transition conference

    Here are some things to think about as you plan to transition from the hospital:

    1. Are you concerned about your risk of falling?
    2. Do you have concerns about paying your bills (such as rent or mortgage, food, medicine or phone bills)?
    3. Who usually helps you with your everyday activities at home?
    4. How would you contact that person?
    5. Who helps you make decisions about your health care (such as making meals)?
    6. Whom do you call when you have questions or concerns about your health?
    7. Do you know what doctor or clinic you can call if you have questions or concerns?
    8. How do you get to your health care appointments?
    9. Who is the main person who helps you get and make your food every day?
    10. Do you need help with medicines?
    11. Do you have concerns about how you will pay for your health care needs?
    12. Do you have memory concerns that interfere with your everyday life?
    13. Have you noticed challenges in planning or solving problems?