Post Discharge Support Program

Post Discharge Support

Depending on the jurisdiction unplanned or avoidable hospital readmissions range from 2% (Obstetrics) to 13.3% (Medical) (CIHI 2012). Costs associated with readmissions not including physician’s fees exceed $2 Billion per year in Canada. This does not include those patients that end up visiting the hospital Emergency Department within the first month of a hospitalization. According to CIHI (2012) research suggests that between 9% and 59% of readmissions may be prevented. These numbers are all much greater for targeted chronic conditions such as emphysema / COPD and congestive heart failure (CHF).

The literature indicates that while appropriate post-discharge planning and an optimized discharge process can ameliorate these problems it is very important to support patients during this very vulnerable post-discharge period.

The Assistance Services Group Approach

The ASG post discharge model is based on evidence and is designed to:

  • Improve communications amongst stakeholders
  • Help patients and their families to adhere to treatment plans
  • Provide an early intervention that can avert an unnecessary visit to the health system
  • Standardize care across the system by providing scale and appropriate integration


By working closely with the patient and their family, the hospital, and the patient’s primary care team Assistance Services Group is able to ensure that every individual within the circle of care is aware of the patient’s status and can intervene as needed. Assistance Services Group can also securely access and distribute targeted individualized care plans to ensure consistency in care delivery.


Every person is different and an appropriate standardized assessment is a key component of the support process. Assistance Services Group can provide standardized assessments and will deliver feedback on patient knowledge, engagement, health status and plan adherence as well as provide feedback to the hospital on the patient’s feedback regarding their inpatient experience. Assistance Services Group can also support vital signs monitoring as needed.

Supporting Healthy Behaviours

Implementing the best practices of several models for post-discharge support Assistance Services Group will:

  • Assess and coach the patient on their use of prescribed medications
  • Remind patients about the relevant provider or diagnostic services appointments
  • Assess and if appropriate refer patients to appropriate in-home services
  • Help the patient and their family if appropriate build a plan to mitigate potential problems

Surrounding the Patient and Family with Care

Assistance Services Group is able to provide 24/7 access to problem assessment and support using individualized care plans as shared by the discharge team and or the patient’s primary care provider. This added layer of support ensures that patients have all the information and support they need before deciding to access the health system.