Photo: Centre for Ageing Better
Publicly funded home care in Ontario runs through Ontario Health atHome, the organisation that took over from the province's 14 Home and Community Care Support Services agencies. It is the single door: whether the referral comes from a hospital, a family doctor or the family itself, the assessment and the funding decision happen there.
You do not need a physician's referral. Anyone can self-refer by contacting Ontario Health atHome directly; the current phone number and referral form are on their website.
What happens, in order
- 1
Referral
You, a hospital discharge planner or a clinician contacts Ontario Health atHome. Hospital referrals move faster because discharge is time-pressured.
- 2
Care coordinator assessment
A care coordinator assesses the person, usually with a standardised interRAI assessment, at home or at the bedside. They look at mobility, cognition, continence, medication, safety and, importantly, how much help family is already providing.
- 3
Service plan
The coordinator decides what is funded and how much. This is a clinical and budget decision, not a negotiation, though you can ask for a reassessment if things change.
- 4
Provider assignment
The actual visits are delivered by contracted agencies, not by Ontario Health atHome staff. You generally do not choose which agency comes.
- 5
Review
Plans are reviewed periodically and after any hospital stay. Hours commonly go down once a short-term post-discharge period ends.
What is funded, and what is not
| Usually funded | Usually not funded |
|---|---|
| Personal support (bathing, dressing, transfers) | Companionship and social visiting |
| Nursing, including wounds, medication, catheters and ostomy | Housekeeping on its own |
| Physiotherapy, occupational therapy, speech-language | Transportation to appointments |
| Social work and dietetics | Overnight and live-in supervision |
| Some medical supplies and equipment | Care above the assessed hours |
How many hours to expect
This is where most families are caught out. A person assessed as needing daily help commonly receives a few hours a week of personal support. That is enough for a morning routine on some days, not enough to cover the day. Post-discharge packages are more generous and then taper.
If the hours are not enough
- Ask the care coordinator directly what would need to change for more hours. The answer is usually a documented change in condition or in family capacity.
- Ask whether the person qualifies for any specialised stream, such as palliative or a high-intensity supports program.
- Request a reassessment after any fall, hospital admission or change in the caregiver's availability.
- Arrange private hours to fill specific gaps rather than duplicating funded visits.
Publicly funded care and private care are not mutually exclusive, and using one does not disqualify you from the other.
Sources
General information, not medical, legal or tax advice. Program rules change, so confirm anything you are budgeting around with the responsible authority.