There is much to consider prior to the care receiver being discharged from hospital; what is relevant will vary depending upon the condition and circumstances of the care receiver. 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 discharge. It is the nurse’s role to contact the Hospital Liaison Nurse (or whoever else has responsibility for discharge planning). This is necessary to determine whether the home care plan needs to be modified in light of the hospital stay, and/or to reinstate services in the home upon arrival.
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 enable joint problem solving and coordination of a plan of care.
Both you and the care receiver (if able) should attend along with all who are directly involved such as:
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, costs, etc. and take notes yourself. Likely there will be considerable detail of which to keep track. Ensure that your responsibilities in the plan are within your capability and resources, and that you and others are clear about these agreements.
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 at your leisure. However, you may not receive permission from everyone 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 agreements are clear.
It is essential that there is a realistic and detailed plan to cover care needs at home, which may include, but are not limited to:
If the hospitalization results in a necessary change in the care receiver’s living situation, such as a move to more supportive housing, to a care facility, or to a rehabilitation facility, discharge planning will need to include a clear description of the options and choices available. Wherever possible, a visit to the new prospective location is advisable so that planning for the move and transition is realistic and sensitive to the impact such a change will have on both you and the care receiver. (See Sections 8 and 10).