Patient in transition of care

Patients that have resolved the need for crtical care are entitled to be  moved through a process in which they participate in the plan development as much as possible.  This may include participation of care givers, family members and or guardians. The process would need to begin before the last day (medical necessity) of hospital care. The facilitated should be a social worker or discharge planner; options could return to home with visiting nurse or medical assistance,, transition to Day Hospital care, Nursing Care, Assisted Living. There could be an occupation therapist engaged to assist patients in transition with adapting to the next level of care ( the core of a Day Hospital Care plan, so that more than one patient at a time could be involved at a session, or sessions, soliciting mutual support.  

Why the contribution is important

Getting patient buy in to the needed change, optimising resource management and staffing through group activity and planning.

Getting the outside hospital resources engaged in the process.

Helping medically impaired patient experience as much autonomy as possible and keeping all parties informed. Avoiding patient dumping, or the accusation, and providing opportunity to treat the whole person with dignity and respect.

It might save money if done with care and real time investment in desired outcome. 

by Kcfitzgibbons on May 29, 2019 at 09:11AM

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