Discharge Planning Flashcards
What is a Discharge Plan?
Discharge planning is an interprofessional approach to continuity of care and a process that includes:
* identification
* assessment
* goal setting
* planning
* implementation
* coordination
* evaluation
and is the quality link between hospitals, community-based services, nongovernment organizations, and carers.
What is involved in Discharge Planning?
- Identify the goals for transition to care in the community
- In a collaborative way, plan for ongoing care
- Include the person’s family, carers, friends and community
- Appoint a discharge planner (case coordinator, continuing care coordinator)
- Liaise with community agencies and services to meet the needs, goals and plans
- Provide support to the person and others in the transition process
Who is a “Discharge Planner”?
Discharge planners are assigned to:
* plan
* coordinate
* and monitor the process of discharge
* And to implement discharge policy to assure continuity of
care.
They coordinate with the patient, family, health-care team,
resources, and services (in-patient, out-patient and community).
Who can be a “Discharge Planner”?
Discharge planners can be:
* Nurses
* Case workers
* Social Workers
* Rehabilitation Counsellors
* Occupational Therapists
* ATSI Health Workers
* Any health worker who can fulfil the role
What should the Discharge Planner do?
Collaboration, Communication, Connection
What should the Discharge
Planner do? Collaboration:
- Work with the Rehab Centre Team to ascertain Bill’s needs
- Share the task of establishing goals and plans
- Use their combined knowledge and experience
- Work as an interdisciplinary team
What should the Discharge Planner do? Communication
- Obtain all available information from the Acute
Hospital and the Rehab Centre - Work closely with Bill and where possible include
other people close to Bill - Liaise with community-based services to establish
opportunities for Bill’s transition and care
What should the Discharge Planner do? Connection
- By working with Bill at the centre of care, find the appropriate services for Bill in the community
- Connect Bill with these services as he transitions to the community
Education
Diabetes is a complex disease and management requires an understanding of:
* Blood sugar control, including measurement
* Nutrition
* Exercise
* Insulin dose and administration
* Recognition of early signs of blood sugar
changes (hyperglycaemia and hypoglycaemia)
* Where to seek support
Who can help?
- Aboriginal and Torres Strait Islander Health Practitioners
- Diabetes Educators
- ATSI Diabetes Health Educators
Australian Diabetes Educators Association.
(2017). National core competencies for Aboriginal
and/or Torres Strait Islander diabetes health workers and diabetes health practitioners.
Canberra: Australian Diabetes Educators Association. - NACCHO run health services (National Aboriginal
Controlled Community Health Organisations) - Community Health Services
Housing
In 2016 more than 116,000 people were homeless in Australia:
* 58% were male
* 20% identified as ATSI
Homeless people have:
* Nowhere to rest and sleep
* Unsanitary conditions
* Poor access to nutritious food and medication storage
* Higher exposure to potential violence and harm
People leaving acute care to homelessness have:
* Higher rates of readmission
* Much poorer health outcomes
Medical respite care
One option is “medical respite care” or “step-down” accommodation
* Transition housing where people can recuperate
* Receive follow-up healthcare
* Get social and economic support
* Be linked to community services including accommodation providers
For the Government:
Respite care = $400 per day
Australian hospital bed = $2,000 per day
Homelessness Services
Available in through different organisations in each state:
* Charity based (e.g. Red Cross)
* Government funded (specialist ATSI services)
* Hospital based
* ATSI Community groups
Often integrated with interprofessional teams including:
* Case workers
* Counsellors
* Financial aid and assistance
* Cultural and social support
