21. Discharge Planning

Question 1

Transfers within acute care hospital

Answer 1

ICU -> ward - > ALC/LTC

• acute care to inpatient rehabilitation facility to home with outpatient rehab

Question 2

Facility discharge: Independent and assisted living

Answer 2

• Seniors apartment to all-inclusive retirement living so you won’t need to worry about day to day chores like preparing meals, housekeeping, maintenance, with games/activities etc

Question 3

Facility discharge: Supportive living

Answer 3

Residents in a supportive living setting can range from seniors who require support services due to age, chronic conditions and frailty to young adults with mental health or physical disabilities. Supportive living includes many different types of settings, such as (but not limited to) seniors lodges, group homes, mental health and designated supportive living accommodations.

Question 4

Facility discharge: LTC

Answer 4

Long-term care facilities are designed specifically for individuals with complex, unpredictable medical needs who require 24 hour on-site Registered Nurse assessment and/or treatment
Recreation staff offer many enjoyable recreation and leisure activities to help promote your wellness and independence

Question 5

Who goes to LTC

Answer 5

Complex conditions: Serious fluctuations in health status requiring immediate health professional assessment
A need for medication management and other treatments
Conditions requiring the continued presence of a Registered Nurse and the consultative availability of rehabilitation or dietary professionals
Unpredictable or unstable behaviour that places the individual or others at risk
Complex end of life care needs

Question 6

Discharge issues

Answer 6

Patient ability - physical
Patient cognitive status - ability to make executive decisions
Patient support - spouse and family
Home setup
Potential for improvement - rehab potential
Available supports/services in community
Qualification for rehab services based on need

Question 7

Equipment needs

Answer 7

• Gait aids
• Home assessment, equipment and modification needs. (Bath rails, tub stools, chair lifts etc) Liaise with other rehab staff - OT

Question 8

What do we look for in strength with discharge planning

Answer 8

1. What are the patient’s strengths
2. What can they do well? What are they having trouble with?
3. And what is necessary for discharge (e.g.) Walking 200m may be nice, but not necessary if they only need to walk 30m to dining room

Question 9

Outcome measure: FIM

Answer 9

the better a patient’s outcome measure score (on FIM, AcuteFIM, NIHSS, etc), the greater the likelihood of home discharge (more likely to go home as opposed to institutionalized care).

Question 10

Outcome measure: walking speed

Answer 10

> 1m/s: independent in ADLs, less likely to be hospitalized, less likely to have AE, D/C to home, community ambulation

<0.6m/s: dependent ADLs, more likely hospitalized, need fall intervention, limited community/house ambulatory

Question 11

Outcome measure: AM-PACK 6 clicks

Answer 11

Assessment of basic mobility and ADL
Good predictor of discharge location (home vs institution) based on mobility and function
Negative is that it is a subscription service that requires payment

Question 12

Discharge: indigenous

Answer 12

Ask direct questions and that there is a plan in place for when they get home.

May need to contact people on reserve to find out about what services are available on reserve or in the surrounding areas.