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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:
    • Home Nursing Care
    • Meals on Wheels
    • Equipment needed at home (wheelchair, commode,  ext. )
    • Oxygen
    • Hospice care

Care Coordination

All care providers know their care roles and responsibilities.

Conduct post-discharge telephone care management.