Discharge Planning
Nipigon District Memorial Hospital endeavors to provide appropriate levels of health care services to all their patients. This occurs while patients are in hospital and as part of the Discharge Planning process.
Coordinating Continuity of Care
Many patients require post hospital care. The need may be for rehabilitation, community support services, long term care or transfer to other communities. These plans must be organized prior to the day of discharge. Successful discharge planning results from thorough assessments and team work which begins on the day of admission to hospital.
Your return home will be a planned, smooth transition. Services considered in your discharge planning will include your need for support from Northwest Community Care Access Centre, Meals on Wheels, Medical Day Care, Respite Services.
Follow up appointments and discharge details will be noted on your Discharge Summary.
Who is Responsible?
Patients and families are responsible for many aspects of their own plan for the care they will need after leaving the hospital. Each member of the health care team involved with the patient provides information about various alternatives available to assist the patient with his/her plan to meet their needs.
How Does the Process Work?
On admission, Nursing staff begin an assessment of:
- patient's medical condition
- home situation
- any problems which may affect discharge
The assessment is documented on the patient's health record. During hospital stay, the patient's progress is reviewed at weekly Interdisciplinary Team meetings to ensure appropriate planning. Ongoing communication between all team members, including physicians and patient/family, is essential. Case conferences with the patient, caregivers, physicians and team members re held for complex situations.
What is the Role of the Discharge Planning Coordinator?
- to screen all admissions for high risk
- to act as a resource person to patients, caregivers and staff
- to ensure appropriate and effective acute care and community resources
- to accept referrals from any service in the hospital regarding patients who require further services
- to act as a contact person for Placement coordination services, Long Term, Care, Chronic Care, LPH Psychogeriatric Team, St. Joseph's Rehabilitation and other community agencies
- in consultation with the physician, designates Alternate Level of Care
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What is the Function of the Discharge Planning Committee?
- to provide weekly review of selected patients to ensure appropriate plans are in place
- to discuss issues which affect utilization and make recommendations to the Medical Advisory Committee
