When the acute care patients have been discharged from a hospital setting, they need a variety of follow-up and long-term services, provided through rehabilitation facilities, home care, chronic care facilities and other programs. Compared to acute care hospitals, relatively little information is reported by other health care facilities and programs.

　For example, after a stroke, amputation, joint replacement or other event, many patients need help in the community by health care professionals to regain and improve basic skills, such as walking, climbing stairs, talking and remembering. Helping people recover these types of skills is the goal of rehabilitation services offered through general hospitals, specialized facilities, home care and other programs.

　Upon discharge from hospital, patients will have various needs for health care services. For example, some will require 24 hour health care versus hourly appointments at home. In Canada, there is a disturbing trend of 'warehousing' in which many clients are in institutions where the care is minimal and there is little rehabilitation. There are large differences between countries in admissions and discharge to and from nursing homes. Various policies, payment schemes, care patterns and routine referrals can be studied with cross national data.

　In Ontario, patients with on-going chronic conditions who need hospitalization may receive what is called "complex continuing care." One study indicated that a "typical patient" was over 70 years of age, female and widowed. Almost three-quarters of patients were transferred from acute care hospitals to other types of health care. The vast majority of complex continuing care patients had at least one chronic condition, many had more.

　

　While some patients spend several years in complex continuing care, most have relatively short stays. Of the participants in the study, half had left the facility by the end of the second year. 36% of these patients died in the institution. Others were transferred to nursing homes (21%), hospitals (14%), or went elsewhere.

　If the patients are not critically ill enough to be institutionalized, home care services is an option after discharge. Many of today's home care services used to be provided in acute and long-term care institutions. Home care allows some patients to recover at home and fill gaps between the services that a client needs and the help his or her family and friends can provide. Some types of medical care, such as dialysis, are now frequently provided at home. Clients discharged to home with a chronic illness, require support services such as adult day care to relieve the family of the responsibility for short periods of time are essential.

　Public home care programs include client assessment, case coordination and management, nursing services and home support, such as Meals-on-Wheels, help with bathing and dressing, homemaking and respite services. Some programs also offer physiotherapy, occupational therapy, oxygen therapy, specialized nursing and other services. The above are examples of extended health care services that may be required by patients in the community after institutional discharge.

　In 1999, the federal government's Health Transition Fund announced funding for the 28 provincial and national home care pilot and evaluation projects. At the present time there are very few evaluations of community care. It is only now in North America that we are making hospitals be accountable for their outcome measures. It is important as we transfer care responsibility from the hospital to the home that we also build in accountability mechanisms that ensure a high level of care.

　Statistics Canada estimates the number of self-reported use of home care programs is about 400,000 or 12%, of Canada's seniors. Use of home care is less common for younger Canadians. People who needed help with activities of daily living-such as preparing meals and housework-were six times more likely to receive care than those who did not need this kind of help. People in the lowest two income brackets were much more likely to receive public home care than those in the highest income bracket.

　In Saskatchewan, one of Canada's provinces, a study was performed. The question they were trying to answer was "What difference did it make whether convalescing patients were cared for at home or stayed in the hospital?" The simple answer is $830 per case. That's the typical difference between what it costs patients, their at-home care givers and the health care system to provide follow-up care in hospital rather than at home with home care.

　It is important that patients and families are systematically involved with decision making. It is important that the discharge planner advocates for the patient and family and discusses all of the options for the patient/family to make an informed decision. Often ethical conflicts arise in respect to balancing patient autonomy with the patient's best interest or safety based on informed decision making.

　Dr. Watanabe's research shows that people prefer to be home if there are adequate services.

　

　Studies have shown that families prefer the patient to be placed in a nursing home as the discharge destination rather than to the family home. As a result of societal and economical changes to the family structure, such as two income families there is no one at home to care for the discharged patient.

　

　Saphir (2000) describes traditional Japanese families as relying on the family members for care. If a family care giver was not available, families often would purchase services from their personal income. In Japan, services are now covered that include activities of daily living, adult day care, medical devices and institutional care.

　In Canada, in a study done in 1998 the services that were accessed the most were the following, homemaking, followed by nursing care, and to a smaller extent meal preparation and/or delivery.