Areas of Care

The Ottawa Hospital Rehabilitation Centre

The Ottawa Hospital Rehabilitation Centre

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Discharge planning 

While you are staying at The Ottawa Hospital Rehabilitation Centre (TOHRC), we will work with you to create a discharge plan that supports your needs after you leave—whether you are going home or to another setting.

You, your family or close friends, and your rehabilitation team will all be involved in planning. We will also connect with community agencies that can help with services and support. 

Three healthcare professionals in scrubs sit around a table, discussing notes and holding pens, with medical documents and clipboards in front of them.

Preparing for discharge 

Discharge planning starts early in your rehabilitation journey.  

Together with your therapist, you will set goals to help you keep the progress you’ve made and prepare you for life in the community.

This may include:

  • Practicing daily activities like climbing stairs or getting dressed.
  • Learning how to use equipment such as walkers or orthotics.
  • Making changes to your home, like adding ramps or lifts.
  • Connecting with community services, such as home care.
  • Learning other skills like managing medications or following a meal plan.

We will also give you information on how to stay well after you leave the hospital. If something related to your treatment comes up and your family doctor cannot help, you can call the nurse listed in your discharge plan. 

Elements of a discharge plan  

Our social workers help coordinate your discharge plan. That plan will cover:

  • A safe place to live after leaving TOHRC.
  • The care and support you may need, and who will provide it.
  • Whether you will continue rehabilitation as an outpatient, through home care, or privately.  This will depend in part on the availability of services and your financial resources.
  • Any equipment you may need and how to pay for it.
  • Emotional and social support for you and your family.
  • Ideas for returning to work or enjoying leisure activities.

You will work with your rehabilitation team and family to make decisions that meet your physical, emotional and cultural needs.

You will also have the chance to talk about how your condition is affecting you and your life. Your family and caregivers will learn how to support you safely and will be able to share how they are feeling too. 

Frequently asked questions (FAQs) 

Discharge planning is the process of preparing for your life after rehabilitation. It starts early in your stay at TOHRC, with you and your rehabilitation team setting goals together. The goal of this process is to help you keep the progress you’ve made at TOHRC and support your transition to the next stage—whether that’s home or another setting. 

You are the most important person in your discharge planning. Your family or close friends, your rehabilitation team, and community agencies will also be involved. If you have trouble with speech, memory, or communication, your family or friends can help with planning. 

While the ideal is to return to your own home, this may not always be possible.  If your home isn’t safe or if no one is available to assist you with self-care and activities of daily living, you may need to move to a place that offers support—like a retirement home, supervised residence or long-term care home. If your home isn’t accessible, you may need to make changes or find a more suitable place to live. 

A social worker will meet with you and your family to talk about your needs. They can help you explore options like supported living, retirement homes or long-term care, and help you with the application process. 

Your social worker will review your financial situation and connect you with community agencies or programs that may help cover the costs. 

Yes. Your occupational therapist will talk with you about your home setup. If needed, they can arrange a home visit to suggest changes that will help you live there safely and as independently as possible. 

Once your rehabilitation team has assessed your needs, they will set an expected discharge date and share it with you and your family. You will be discharged when you’ve reached your rehab goals. If your goals change, your team will adjust the plan and update the date. 

You may return to the hospital where you were before coming to TOHRC. You’ll stay there until a long-term care bed becomes available or your home is ready. While there, you and your family can continue practicing the skills you learned at TOHRC. 

Weekend visits home are encouraged. They give you and your family a chance to see what works well and what challenges still need to be addressed before your final discharge. These visits help your team fine-tune your plan. 

We understand that leaving the hospital can feel overwhelming. Our team is here to support you and your family every step of the way. Most people find that with good planning, the transition to the community goes smoothly. 

Contact us

The Social Work Secretary

 613-737-8899 ext. 75322

The Ottawa Hospital Rehabilitation Centre    
Room 1209 
505 Smyth Road, Ottawa, ON  K1H 8M2