The oncology social workers work as part of the multidisciplinary team when a patient is hospitalised to determine what the patient and family’s’ needs were when deciding on the need for hospitalisation .
The following aspects will be considered when compiling the discharge plan for each patient
Discharge Planning – Process
Conduct pre-discharge assessment of ability of patient/family to provide self-care (includes problem-solving, decision-making, early symptom recognition, and taking action, quality of life, depression and other cognitive and functional ability factors)
Develop a comprehensive shared care plan using a shared decision-making approach – consider patient values and preferences, social and medical needs
Discharge summary and medication plan are complete and up to date
Work with patient/family to prepare for the post discharge visit planning (goals, questions, concerns)
Work with patient/family to complete advance directives as appropriate
Discharge Planning – Content
Written discharge plan can include the following:
· Reason for hospitalisation
· Medications to be taken post discharge, including, as appropriate, resumption of pre-admission medications.
· Self-care activities such as diet, activity level or limitations, weight monitoring
· DME/supplies that patient will need for care
· Symptom recognition and management – what to do if patient has a question, a problem arises or condition changes, including of symptoms of which to notify health care provider
· Coordination and planning for follow-up appointments
· Coordination for follow-up of test and studies for which confirmed results are not available at the time of discharge.
· Coordination of community resources patient will utilise, such as:
o Home Nursing Care
o Meals on Wheels
o Equipment needed at home (wheelchair, commode, ext. )
o Hospice care
All care providers know their care roles and responsibilities
Conduct post-discharge telephone care management