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Post-Hospital Discharge Follow-up

Overview

Transitioning from the hospital to home can be challenging. Our Post-Hospital Discharge Follow-up program provides comprehensive support for a safe and smooth recovery. Our collaborative team of nurses and providers works with your family doctor to review discharge instructions, coordinate follow-up care, and answer your questions. Our primary goal is to prevent complications and readmissions through clear, timely support, creating a crucial bridge of care during your recovery.

Requirements
Recent hospital discharge
Provider

Nurse, Family Doctor, other FHT Providers as needed

Eligibility
Rostered patients of Queen Square Doctors
Fees
Covered for rostered patients

About

What is this program about?


This program is designed to provide a crucial bridge of care for patients transitioning from a hospital stay back to their homes. The primary goal is to ensure a safe recovery, prevent complications, and reduce the risk of hospital readmission by providing coordinated follow-up care.




Who is this for?


This program is for rostered patients of Queen Square Doctors who have been recently discharged from a hospital stay.




How do patients access this program?


Patients of Queen Square who have been recently discharged from the hospital will be contacted by our team to initiate this program. It is typically accessed via a notification from your hospital care team to your family doctor upon your discharge.




What can patients expect?


Shortly after you return home, you can expect a member of our team, usually a nurse, to contact you. They will review your discharge instructions and help schedule any necessary follow-up appointments with your family doctor or other family health team providers.




What services are included?


Support from this program may include:


  • Education for you and your caregivers about your condition and recovery plan.

  • Coordination of follow-up appointments.

  • Monitoring for any post-discharge complications.

  • Ensuring a clear line of communication between you, the hospital, and your family doctor.

Have Questions About Your Discharge?

This program is typically initiated by your care team. However, if you have recently been discharged and have not been contacted, or if you have urgent questions about your care, please contact our clinic directly.

Want To See Your Doctor?

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Doctor's Clinic

366 Main Street North - Suite 201
Brampton, ON

Family Health Team

366 Main Street North - Suite 203

36 Vodden St East - Suite 307

Brampton, ON

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Queen Square Family Health Team operates on the Treaty Lands and Territory of the Mississaugas of the Credit First Nation. We acknowledge the territory of the Anishinabek, Huron-Wendat, Haudenosaunee and Ojibway/Chippewa peoples; the land that is home to the Metisl and most recently, the territory of the Mississaugas of the Credit First Nation who are direct descendants of the Mississaugas of the Credit. We are grateful to have the opportunity to work with and serve the people who inhabit this land, and by doing so, give our respect to its first inhabitants.

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