We ensure nothing is missed when you leave the hospital
Post-discharge is one of the highest-risk windows in any recovery. Our registered nurses coordinate a structured, phase-based transition from hospital to home — so neither you nor your caregiver is left overwhelmed.
Phase-Based, Not Hourly
Each phase is designed around clinical milestones — not a clock. You get exactly what you need at the right time, without paying for what you don't.
For Client and Caregiver
We prepare both the patient and the family. Clear instructions, red-flag education, and medication setup mean no one is left guessing.
Early Detection Saves Readmissions
Most 30-day readmissions are preventable. Our follow-up monitoring catches warning signs before they escalate into emergency visits.
Three phases. Zero guesswork. Designed so nothing slips through.
Discharge Day Support
At the hospital — on the day of discharge
The moment of discharge is confusing and rushed. We are there in the room to make sense of it.
- Translates discharge instructions into plain, accessible language
- Reconciles all new and existing prescriptions for conflicts or omissions
- Clarifies outstanding orders directly with the hospital nurse or physician
- Confirms and arranges the first follow-up appointment before leaving
- Coordinates safe transport home
First Home Visit
Within 24 – 72 hours after discharge
The first 72 hours at home carry the highest risk. This visit covers everything, systematically.
Clinical Assessment
- Vital signs assessment: blood pressure, heart rate, oxygen saturation, and temperature
- Wound, tube, or catheter inspection
- Symptom screening for early signs of infection or deterioration
Medication Setup
- Organises pill box by dose and time of day
- Confirms all prescriptions are filled and correct
Patient & Caregiver Education
- Explains dietary and activity restrictions clearly
- Reviews red flag signs: when to call the nurse and when to attend the ER
Home Environment
- Assesses bed setup, mobility, and fall risk
- Identifies and flags immediate safety concerns
Follow-Up Monitoring
Day 3 and Day 7 post-discharge
Most complications emerge silently in the first week. Two structured check-ins close that window.
- Condition trend review to assess whether recovery is progressing as expected
- Medication adherence check to confirm doses are taken correctly and consistently
- Early complication screening for pressure injuries, fluid retention, and infection
- Care plan adjustment based on current clinical status
- Caregiver debrief to address questions and reinforce updated guidance
1 in 5 patients is readmitted within 30 days of discharge. The majority of these readmissions are considered preventable with structured post-discharge follow-up.
Nurse-led home transitions have been shown to significantly reduce medication errors, falls, and early complications — the three leading causes of post-discharge hospitalisation.
Patients Who Benefit from Structured Discharge Support
Our post-discharge programme is designed for patients navigating elevated clinical risk following hospitalisation. Structured nursing support has the greatest impact where medical complexity, social isolation, or caregiver inexperience is present.
How It Works
From first contact to final check-in, the process is designed to be simple and stress-free — even during one of the most difficult weeks of your family's life.
Reach Out
Call, message, or book online. Ideally before discharge — but we can also begin after you're already home. We respond quickly.
We Plan Your Care
A registered nurse reviews your discharge summary, medications, and home situation. We confirm which phases are most appropriate and schedule visits around your timeline.
We Show Up
Your nurse arrives at the hospital for discharge support, or at your home within 72 hours. You focus on rest — we handle the clinical details.
We Follow Through
Structured check-ins at day 3 and day 7 close the highest-risk window. A written summary is shared after every visit — so nothing is left unclear.
Related Services
Post-Discharge Care is part of a complete continuum of nursing support.
Medical Escort
Nurse accompaniment to follow-up appointments after discharge, with real-time advocacy and a written clinical summary.
Learn MorePrivate Care at Home
Scheduled nurse visits for ongoing clinical support, wound care, and medication management beyond the discharge window.
Learn MoreHospital Bedside Support
In-hospital nursing presence before discharge — advocacy, communication, and family liaison during the admission itself.
Learn MoreNot Sure Where to Start?
Tell us your situation and we will recommend the right combination of services for your recovery.
Contact UsPhase-Based Pricing
Each phase is priced as a service package, not an hourly rate. You know exactly what is included before you commit.
Core
Nursing visit within 72 hours of discharge. Covers clinical assessment, medication setup, wound care, and home safety.
Includes:
- Registered nurse home visit within 24–72 hours
- Full vitals assessment (BP, HR, SpO₂, temp)
- Wound, tube, or catheter inspection
- Medication box setup and prescription confirmation
- Dietary and activity restrictions explained
- Red flag education for patient and caregiver
- Home safety and fall-risk environment assessment
- Written clinical summary shared with family
- HSA/FSA-eligible itemised receipt
Plus
First home visit with structured Day 3 and Day 7 check-ins. Covers the window when most complications appear.
Includes:
- Everything in Phase 2 (First Home Visit)
- Day 3 follow-up visit: condition trend review
- Day 7 follow-up visit: full reassessment
- Medication adherence check at each visit
- Early complication detection (pressure injury, oedema, infection)
- Care plan adjustment based on recovery progress
- Caregiver reinforcement at each visit
- Two additional written clinical summaries
- Priority scheduling guarantee
- HSA/FSA-eligible itemised receipt
Complete
All three phases: hospital coordination on discharge day, first home visit, and Day 3 and Day 7 follow-up. Best for complex cases.
Includes:
- Everything in Phase 2+3 package
- Phase 1: Nurse present at hospital on discharge day
- Discharge instruction interpretation in plain language
- Medication reconciliation against all existing prescriptions
- Clarification of outstanding orders with hospital team
- Follow-up appointment arranged before leaving hospital
- Transport coordination home
- Seamless handoff from hospital to home
- HSA/FSA-eligible itemised receipt
Need ongoing support?
Recovery takes longer than a week.
For clients who need nursing support beyond Phase 3, we offer custom ongoing care plans — weekly visits, medication management, and chronic condition monitoring. No fixed contract required.
Talk to our teamLeaving hospital soon? Let's plan ahead.
The best time to reach us is before discharge — not after. Contact us now and we'll coordinate everything with your hospital timeline.
Get in touchResources
When to Seek Medical Attention After Discharge
Read moreWhy Recovery Outcomes Change at Home After Discharge
Read moreMedication Management After Discharge: Why It Becomes Complex at Home
Read moreThe First 72 Hours After Discharge: What to Expect and Watch For
Read moreWhen to Seek Medical Attention After Discharge
Read moreFrequently Asked Questions
Common questions about our Post-Discharge Care programme.
Most home care is hourly and reactive. Our post-discharge programme is structured around clinical milestones — Phase 1 at discharge, Phase 2 within 72 hours, Phase 3 at day 3 and day 7. Each phase has a defined clinical purpose, not just supervision.
No. Phase 1 is an optional add-on. It is most valuable when discharge instructions are complex, medications have changed significantly, or the patient and family feel uncertain about what was explained at the hospital.
Anyone returning home after a hospital admission — whether following surgery, a cardiac event, a fall, infection, or any condition requiring inpatient care. It is especially relevant for older adults, individuals with multiple health conditions, and families where the primary caregiver needs clinical guidance.
We strongly encourage continuity. Whenever scheduling allows, the same registered nurse handles all phases of your programme. This ensures clinical consistency and builds trust between nurse, client, and family.
Yes. Most clients engage us directly for Phase 2. If you are already home and within 72 hours of discharge, we can schedule the first home visit promptly. Contact us and we will arrange this as a priority.
Our nurses are trained to triage. If a clinical concern requires immediate attention, we will advise on emergency care and can accompany the client to the emergency department if needed. Family members are contacted directly.
Yes. After every phase visit, a written clinical summary is shared with the client and designated family contacts. This covers findings, medications reviewed, red flags identified, and any care adjustments made.
Post-Discharge Care is not covered by OHIP. Many extended health benefits or health spending accounts (HSA) may cover registered nursing services. We provide itemised receipts for all phases. Please confirm eligibility with your provider.
We aim to confirm Phase 2 within 24 hours of your request. For planned hospital discharges, we recommend contacting us 48 hours in advance so we can coordinate the timeline with your discharge team.
Yes. With your consent, we can share the clinical summary with your primary care provider or specialist, flag urgent findings, and assist with securing follow-up appointments. Continuity with your existing medical team is a core part of what we do.
Still have questions? Our team is ready to help.