Discharge planning

Discharge planning

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    Oxygen

o    Hospice care

 

Care Coordination
All care providers know their care roles and responsibilities

Conduct post-discharge telephone care management

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