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LivingHealthDischarge planning and transitions within the healthcare system

Discharge planning and transitions within the healthcare system

by Hannah Larkin

Individuals are admitted to the hospital for a variety of reasons.  No matter the reason, there comes a time when this reason for admission has been investigated and an individual no longer requires acute hospital services.  For some, the next step is a discharge to home or to an alternate care facility in the community, such as a retirement home, while for others a transfer to an alternate inpatient program, such as rehabilitation, will be required.

Discharge Planning is the process used to identify and prepare for these transitions.

The Discharge Planning process often begins shortly after an individual enters hospital with an initial assessment of the individual’s previous level of functioning, home setup, and social supports.  This assessment is referred to as a psychosocial assessment and helps inform the hospital’s interdisciplinary team, consisting of Physicians, Nurses, Physiotherapists, Pharmacists, Occupational Therapists, Dieticians, and Social Workers, about an individual’s care needs.

With these needs in the mind, the hospital team will meet with the individual and/or their decision makers to discuss the next transition and to create a Discharge Plan.  This process is designed to support the individual in their next steps and to answer key questions including “where will I go”, “who will help me”, and “what equipment will I need”.  When a discharge date and destination are determined, the interdisciplinary team will complete any appropriate referrals, such as to the Community Care Access Centre (Home Care) and can provide information to assist the individual and their family to arrange for other necessary equipment and support.

Overall, the interdisciplinary team recognizes that transitions both between healthcare programs and back to the community often come with mixed emotions which can be eased by arranging appropriate supports and creating a cohesive, safe Discharge Plan.

Hannah Larkin is the new Manager of Patient Flow at the Almonte General Hospital.  Hannah is a native of Mississippi Mills and holds a background in Social Work with a focus on Gerontology. 




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