There is much to consider prior to the care receiver being discharged from hospital. The condition and circumstances of the care receiver will influence the discharge. If the care receiver was on the Home and Community Care Program before going into hospital, you will want to notify the nurse on the unit to arrange for a reassessment prior to leaving. It is the nurse’s role to contact the Discharge Planning, Social Worker or Hospital Liaison Case Manager to determine whether the home care plan needs to be modified and/or to start up the services in the home.
If the care receiver was not on the Home and Community Care Program before coming into the hospital, and will now require assistance at home upon discharge, you will want to notify the nurse on the unit so that he/she could co-ordinate the necessary steps.
Discharge planning conference
When changes to the care recipient’s health or level of care required are extensive or complex, a discharge planning conference (usually facilitated by a social worker) will identify problems to be solved and coordinate a plan of care. Both you and the care receiver (if able) should attend along with all who are directly involved such as:
- Physician/specialist (often unable to attend)
- RN
- Social worker
- Dietician/nutritionist
- Physiotherapist
- Occupational therapist
- Hospital Liaison Nurse, Case Manager, Residential Care Coordinator
Your preparation should include writing out questions or areas you are unsure of, and any concerns you and the care receiver have identified. During the meeting, be prepared to ask lots of questions regarding needs, arrangements, who to contact and how, and costs. Take notes to keep track of al the information. Ensure that your responsibilities in the plan are clear, realistic, and work with the other services.
Notes should also be taken to document the discussion and conclusions of the conference (you may even want to ask if it is okay to tape-record the meeting so that you can review the planning details. However, you may not receive permission from every¬one in attendance to do this, and if so, you will have to rely on your own notes). If minutes are taken, you and/or the care receiver should receive a copy to ensure that all plans are clear.
The Plan
The plan should be clear, realistic and detailed to cover care needs at home, which may include:
- Personal care needs and staff identified (i.e., home support workers). If the individual received these services before, they may need to be increased during the recovery. The Community Liaison Nurse or Case Manager or Residential Care Coordinator will be needed for a reassessment or to allow for changes. If new services are needed, a referral to Home and Community Care Program is required.
- Health care professional referrals for nursing care, social worker, physiotherapy, occupational therapy, speech therapy, or dietician.
- Changes to the home, i.e., bathroom grab bars, wheelchair ramp, etc. (An occupational therapist, will be helpful to do a home assessment).
- New equipment required (i.e., lifting devices, a special bed, or mobility aides such as a specially fitted cane or walker). These items may need to be purchased or borrowed, and ordering them may fall to you. (Agencies that loan medical equipment may be available in your area, and should be explored, particularly if the item is to be used short term, or if it requires a period of trial.)
- Supplies such as incontinent products, or dressing ointment and gauze.
- New medication or changes with written instructions, including the drug name(s), amount, and time of day to be taken, and any special advice about managing them. (Note: at the time of actual discharge, ensure that you know when the last dose of each medication was given in the hospital).
- Other community supports that may be needed, such as meals on wheels, cleaning, volunteer driving, or adult day programs.
Adapted from: Family Caregivers' Network Society, Resource Guide for Family Caregivers, 2006.