Hospital-to-Home & Recovery Support
About this service
We smooth the transition from hospital or ER back to home so recovery is safer and less stressful. Working from Alberta’s Home to Hospital to Home (H2H2H) guideline, we coordinate instructions, reconcile medications, ready the home/equipment, schedule follow-ups, escort to appointments, and watch early warning signs to prevent avoidable readmissions. When an AHS case manager authorizes hours, portions of this support (e.g., personal care and essential health-linked homemaking) can run under CDHCI with approved hours billed to Alberta Blue Cross; families often add private top-ups for transportation or extended nursing. We document succinctly, follow AHS Routine Practices for infection prevention, and share concise updates with families and providers.
Who it's for
- People leaving hospital, day surgery, or the emergency department who need short-term, structured help at home (e.g., wound care, mobility support, med changes, new equipment). H2H2H stresses coordinated handovers and early follow-up.
- Adults with conditions where early deterioration is common (HF/COPD/diabetes), who benefit from vitals/weight checks and timely escalation.
- Families who want a named point person to align hospital instructions with primary care and community services (Home Care, AADL vendors, rehab).
What´s included in the service?
Discharge coordination (pre-leave)
With consent, we confirm the discharge plan, meds, wound/line care, and red-flags; sync with your AHS case manager or arrange access if you don’t have one yet (call 811 or Continuing Care Access).
Medication reconciliation & setup
Nurse checks changes, organizes dosettes/blister-packs with your pharmacy, and builds reminder routines; we clarify who gives what/when and document any PRNs.
Home safety & equipment readiness
Clear transfer paths, set up a recovery zone, and coordinate AADL authorizer/vendor for approved items (e.g., walkers, commodes, hospital beds) where eligible.
Initial 48–72-hour check
Focused visit for vitals, pain, wound/skin review, hydration/nutrition, bowel/bladder status, and symptom screening; we use Routine Practices (hand hygiene, device cleaning) every visit.
Escorted follow-ups & tests
Book/confirm appointments, provide door-through-door escort, and return with plain-language notes for family and the care team.
Monitoring & escalation
Simple logs (weights/BP/O₂ as ordered) with pre-agreed thresholds for when to call your nurse/clinic or seek urgent care—consistent with H2H2H’s emphasis on clear action plans.
Care plan updates
Share changes with your family doctor/Patient’s Medical Home; the AMA H2H2H change package supports this primary-care linkage.
Frequently asked questions
How do we access public-funded hours for recovery support?
Start with AHS Home & Community Care: a case manager assesses your needs and can authorize service types/hours. If CDHCI is chosen, approved hours (e.g., personal care, essential health-linked homemaking, in-home respite) are billed directly to Alberta Blue Cross; you can add private top-ups for extras like transport or extended nursing.
What’s special about Alberta’s H2H2H approach?
It’s a province-wide transitions guideline that defines key actions across hospital, primary care, and community teams so patients and families experience a single, coordinated journey with timely follow-up.
Can you help if equipment is needed at home?
Yes. We coordinate assessment with an AADL authorizer and ordering through approved vendors when the client meets criteria; we also set up and teach safe use. (AADL has defined product lists and cost-sharing rules.)
What infection-prevention steps do you follow during early recovery?
We apply Routine Practices on every visit (point-of-care risk assessment, hand hygiene, risk-based PPE, and cleaning of any devices and high-touch surfaces we used), per AHS community guidance.
We weren’t assigned a case manager at discharge—what now?
Call 811 or the Continuing Care Access Line (1-855-371-4122) to get started with AHS Home Care in your zone; a case manager/Registered Nurse will assess and plan services.
Download our guide
Check out our guide to Home and Community Care.