We've all heard the stories of people being discharged from hospital without the support they needed in place. It does happen, but you can play a part in avoiding this.
It helps to understand a bit about how discharge planning works. The hub of it starts, not with your doctors, but with your nurse and especially the charge nurse.
The focus of the team is primarily to address that medical issue you've been admitted for. They don't know of your home situation and may not ask. If you or a family member has any concerns about you needing some help when you get home, then tell your nurse as early as possible in your admission.
Your nurse, in turns, tells the charge nurse. The charge nurse then makes referrals to the appropriate health team members. Usually this is the Physiotherapist (PT), Occupational Therapist (OT), Care Coordinator (CC), and the Social Worker (SW). Every unit the hospital has these team members but they only get involved if they have received a referral.
The PT will assess your mobility and transfers, prescribe exercises, work with you to improve your mobility and recommend a walking aid.
The OT will assess your ability to use the bathroom, dress, feed, bathe, groom, and cook. They will recommend equipment for home like a bath seat, raised toilet seat or wheelchair.
The SW helps to get funding, provides emotional support, and connects you to resources in the community like Meals on Wheels and adult day programs.
The CC assesses and arranges for Continuing Care programs and services like home care workers and VON nurses.
They could be other team members consulted, like a pharmacist, dietitian, palliative care team or diabetics manager.
It can be busy and confusing. Have one support person write things down and for the team to speak to. You or they can ask to speak to any of the team members by asking your nurse.
On the day of your discharge you will receive a written discharge summary for your family doctor describing what you came to hospital for, what happened while in hospital, and what follow-up appointments you have as well as a list of medications you are on, and prescriptions for any new medications.
Planning for a good discharge starts when you are admitted, and you can help by talking to your nurse about your needs.
Marie-Claire Chartrand, is the lead senior care consultant for Greywave Senior Care Consulting and develops plans customized to the needs of clients and families.
Marie-Claire’s practice is based on her 30-year career with Nova Scotia’s Continuing Care Program.
She has unparalleled experience helping clients navigate the private and public health care systems.
Marie-Claire is a Licensed Social Worker and has worked across the healthcare spectrum, in hospitals and the community, with both palliative and geriatric clients and their families.
Marie-Claire has a Social Development Studies degree from the University of Waterloo and a Masters degree in Theological Studies from the Atlantic School of Theology.
She is Nova Scotia’s only Elder Mediator, certified by Family Mediation Canada. She is skilled at helping clients manage complex family relationships to achieve their goal of helping loved ones.
Marie-Claire provides services in both English and French.