Ontario Health atHome Assessment: What to Expect and How to Prepare

How the Assessment Process Works

Ontario Health atHome is the single provincial agency that coordinates all publicly funded home care and long-term care placement. When your parent needs support, the assessment is the gateway to everything — personal support workers, nursing visits, therapy, and eventually long-term care eligibility.

No doctor's referral is needed. Anyone — you, your parent, a neighbour — can call 310-2222 (no area code) or 1-833-515-1234 to start a referral. Ontario Health atHome assigns a care coordinator who schedules an in-home visit; timing depends on the urgency and circumstances.

The care coordinator is a registered health professional — typically a nurse or social worker — who becomes your parent's ongoing point of contact for all publicly funded care services.

What the Care Coordinator Evaluates

The assessment uses the Resident Assessment Instrument — Home Care (RAI-HC), a standardized clinical tool that scores your parent across several domains:

• Cognitive function — memory, decision-making ability, communication
• Physical function — mobility, transfers, bathing, dressing, toileting, eating
• Behavioural patterns — wandering risk, aggression, resistance to care
• Medical complexity — medication management, wound care, chronic conditions
• Caregiver capacity — who provides informal support, how sustainable that support is, signs of caregiver burnout

The RAI-HC generates clinical scores like the Cognitive Performance Scale (CPS2) and the Activities of Daily Living Hierarchy Scale (ADLH). These findings inform the care plan; the scores do not by themselves guarantee a specific number of funded hours.

The coordinator also runs the Caregiver Risk Evaluation (CaRE) algorithm, which flags whether your family's informal support network is under strain. Caregiver circumstances are considered in the assessment and care plan; a collapsed network can support a reassessment and may affect placement priority.

How to Prepare for the Visit

The assessment is not a test your parent can fail, but how it goes shapes the care plan. Families who prepare get more accurate results — and more appropriate services.

Before the visit:

• Write down every fall, emergency room visit, and close call from the past 90 days. Frequency of falls is one of the strongest triggers for higher-level services.
• List all medications with dosages. Note any compliance problems — missed doses, double-dosing, or refusal.
• Document the daily routine: who helps with what, how many hours per day, and where the gaps are. If you are spending 20 hours a week providing care, say so — the CaRE algorithm needs that data.
• Have your parent's OHIP card ready.

During the visit:

• Be honest about the hard days, not just the good ones. Families often minimize problems during assessments, which leads to inadequate care plans. If your parent left the stove on twice last month, the coordinator needs to know.
• Ask the coordinator to explain the CPS2 and ADLH results and how they informed the care plan. Understanding the results helps you advocate for your parent if you disagree with the care plan later.
• Ask about the maximum personal support hours available. Publicly funded home care is capped at roughly 60 hours per month for personal support, so knowing the ceiling helps you plan for private top-ups if needed.

What Happens After the Assessment

The care coordinator builds a care plan based on the RAI-HC results. This plan specifies the type and frequency of services — personal support worker visits, nursing, physiotherapy, occupational therapy — and assigns a Service Provider Organization (SPO) to deliver them.

The timing of services depends on the care plan, urgency, and provider availability. If the coordinator determines your parent's needs exceed what home care can safely provide, they will discuss long-term care eligibility and begin the placement process.

If you disagree with the care plan — if the hours seem too low or a service was denied — you can request a formal internal review through the Ontario Health atHome Patient Services Manager. If that does not resolve it, you can appeal to the Health Services Appeal and Review Board (HSARB) within 30 days.

The assessment is not a one-time event. The care coordinator reassesses periodically, or sooner if your parent's condition changes. A hospitalization, a new diagnosis, or a significant decline should prompt an immediate reassessment request.

Getting Started

If your parent is struggling at home and you are not sure where to begin, the assessment is the first concrete step. Call 310-2222 to start the referral — it costs nothing, no doctor's note is needed, and it starts the assessment pathway for publicly funded home and continuing-care services.

For a complete walkthrough of the Ontario continuing care system — from the initial assessment through long-term care placement, Bill 7 hospital discharge rules, and the Rate Reduction Program — the Ontario Continuing Care Navigator covers every step with checklists and intake scripts you can use during the process.

See more Ontario guides →