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Discharge Planning - The Facts
Source: The Care Guide
Definition of Discharge Planning
Social workers engaged in discharge planning coordinate discharges for
patients by collaborating with the patient, family, health care team and
community resources. The social worker is involved with the early identification
and assessment of the patient's needs and implements timely discharge plans that
result in continuity of care and efficient use of hospital and community
Discharge planning is a process that includes identification, assessment,
goal setting, planning, implementation, coordination and evaluation.
Components of Discharge Planning
Source: The Association of Discharge Planning Coordinators of
Ontario (ADPCO). Hospital Discharge Planning: A Balancing Act, May 1997.
In order to coordinate timely discharge plans, the social worker uses the
discharge planning process to:
- Promote early identification and assessment of patients requiring assistance
with planning for discharge.
- Collaborate with the patient, family and health care team to facilitate
planning for discharge.
- Recommend options for the continuing care of the patient and refer to
accommodation, programs or services that meet the patient's assessed needs and
- Liaise with community agencies and care facilities to promote patient access
and to address gaps in service.
- Provide support and encouragement to patients and families during the stages
of assessment and discharge from the hospital.
Source: The Canadian Association of Discharge Planning and Continuity
of Care (CADPACC) : Guidelines and Standards for Discharge Planning
Coordinators, May 1995.
Some Discharge Options
Depending on the care needs of the patient, there are a variety of possible
options for discharge. Some of these options include:
- Home alone with family support
- Home with private agency supports such as nurses, sitters, personal care
workers, health care aides
- Home with support from community agencies such as Meals on Wheels, seniors
- Home with CCAC (Home
Care) support if eligible
- Retirement home for short-term convalescence or for a permanent stay
- Supervised boarding home
- Rehabilitation services such as Geriatric, Stroke and Head Injury
- Return to the referring hospital
- Long-term Care facility (nursing home)
- Complex Continuing Care facility (chronic care)
- Palliative Care hospital/hospice
Retirement homes are privately owned and operated residences. Each home
provides accommodation, meals and recreational activities. The assistance they
offer varies and can include help with bathing, supervision of medication and
assistance with dressing. Some homes include all services in their costs that
can range from approximately $1,500 to $4,000 per month depending on the type of
room and services provided. Assisted Living units are available in some
residences at a greater cost. Some other residences do not provide a separate
Assisted Living unit, but bring the increased care to your room. Check with the
individual retirement home to determine what services are available and whether
they can meet your care needs.
Applications are made directly to the
retirement home. A very small number of these residences have subsidized beds
that are administered by the City of Ottawa.
On-line guides exist to
assist in the selection of a retirement home:
The Ontario Residential
Care Guide - Care Planning Partners Ltd
Convalescent care and respite care convalescent care is designed to offer a
period of recuperation for individuals recently hospitalized who may need
additional care to recover their strength, endurance and functioning.
Respite Care offers a period of rest to family caregivers of people living in
their own home by allowing the patient to enter a care facility for a short
period of time. These services may help individuals remain in their homes as
long as possible.
Convalescent and Respite Care in Retirement Homes
Retirement Homes offer short-term accommodation for convalescence (usually
under 1 month stay) and respite care. These homes are privately operated and
services vary from home to home such as medication administration, personal care
and assistance to the dining room. If you are fairly independent, the cost is
approximately $50-$100/day depending on the residence. If you need increased
care the cost could be higher. In many facilities the convalescent/respite costs
are at a reduced rate for the initial period and will increase after a period of
time (usually 1 month).
Short Stay Program
While you are in hospital, your social worker
will provide you with the necessary information and assist you with the
discharge process. Some facilities will ask social workers to provide a written
assessment of your level of functioning and specific care needs. Any agreements
regarding room rates, cost for various amenities (e.g. telephone, cable) and
additional costs for personal care are made directly between you and the
If you are aware that you will be coming in to hospital for
surgery, it can helpful to tour some of the retirement homes that provide
convalescent care before your surgery date to determine which ones you like.
This can also help you know what to expect should you go to a retirement home
for convalescence upon your discharge.
Another option for convalescent (supportive) care and respite care is the
Short Stay Program available at a few Long-term Care facilities (nursing homes).
These beds are administered by the Community Care Access Centre (CCAC). If you are in hospital,
your social worker will assist with the application process. From home, you can
call the CCAC at 613-745-5525 for information.
Making the decision to apply for long-term care placement can be a difficult
and emotional process. It is not easy to know when the time has come to make
this very significant change in one's life. You may wish to involve family
members or other support persons in your decision making. While in hospital,
your social worker and other members of the health care team can also
Referral and Application to Long-term Care
You may refer yourself or someone else may refer you. If you are in hospital,
your social worker will make the referral and will complete the application
process to ensure all the necessary forms are submitted. Once they are
completed, the forms are forwarded to the local Community Care Access Centre
(CCAC). The CCAC will determine your eligibility for long-term care
placement and ensure that you are put on an appropriate waitlist for the
facilities you have chosen.
Awaiting Placement From Hospital
If you are going to await placement from hospital, there are specific
guidelines to follow. Your social worker will explain these to
Awaiting Placement From Home
If you plan to await long-term care placement from home, you may select any
facility of your choosing. The CCAC will assist with the application process,
determine your eligibility and place you on the waitlists for your chosen
facilities. Further information about placement from home can be found on the OACCAC's web site.
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