Discharge Planning & Home Health Care

Discharge planning is a process used to decide what a patient needs for a smooth transition from hospital to home. Only a doctor can authorize a patientʼs release from the hospital, the actual process of discharge planning is completed by a nurse, case manager, occupational therapist, or social worker. Ideally, and especially for more complicated medical conditions, discharge planning is done with a team approach.

The general basics of a discharge plan are:

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Patients, family caregivers and health practitioners all play a role in maintaining a patientʼs health after discharge. At Apex we employ compassionate and caring nurses, support workers, social workers and case managers to provide consistency and attention to detail through this process.

Case Management

A Case Manager is a very important component of the rehabiliative team. Case Managers ensure that the home environment is assessed prior to a patient being discharged to ensure all modifications are completed and assistive devices installed.

They also help in arranging the proper assessments needed, treatment planning, and provide overall case supervision. This helps to ensure that all treating practitioners, doctors, lawyers etc are on the same page and kept up to date of the patientʼs progress.

Another important role of the case manager is life planning. They will summarize medical, educational, psychosocial, vocational and daily living needs of the patient to project long term costs of care. This is of utmost importance to ensure rehabilitative goals continue and future cost of care providers are in place to assure continued support and recovery.

Home Care

Upon returning home, an injured patient will need an Attendant Care Assessment completed to determine what help is needed. This includes determining help with activities of daily living, light cleaning, cooking, shopping etc.

In addition, this assessment takes into account any safety concerns in and around the home and provides solutions to any issues. Examples include safety bars in the shower, a ramp to enter a residence, and therapy devices to facilitate recovery.

Personal support workers, Occupational Therapists, case managers and rehabilitation support workers are involved in the home care process. Collaboratively, their role is to ensure the safety and well-being of the patient by providing high quality care and communicating with all stakeholders.