Hospital discharge planning

Short or long term stays in hospital can be stressful for both the patient and their family and there is often concern for how their health and wellbeing can be managed after they leave the hospital environment. It is critical that the hospital departure is planned in advance as research has proven that improving the hospital discharge planning can significantly improve a patient’s outcome through the provision of suitable care.

What is hospital discharge planning?

While it is a doctor who is responsible for the patient’s release from hospital, the discharge planning is usually completed by a social worker, case manager, nurse or allied health professional. Generally the best discharge planning involves a team of people who are approaching the plan with a holistic view, to ensure the patient receives the right level of care and support in the most appropriate environment.

There are many different components of a discharge plan including

• Evaluation of the patient’s health and circumstances
• Discussion with the patient and or their family
• Planning for the facility to which they’ll be transferred, whether it is home or a nursing care environment
• Decision whether training or other support is needed for carers
• Referral to a appropriate support organisations
• Arrangement of follow-up tests, introductions and services

Can discharge planning involve access to care packages?

Depending on the physical condition of the person prior to and after the hospital stay, and the facility to which they will be moving, they may be eligible for a Transition Care Package (TCP). Importantly this package eligibility has to be determined prior to them leaving hospital so they need to be assessed while they are still a hospital patient (see Transition care: Accessing care after hospital)

If they are eligible for a TCP they can access a range of services and support including allied health and personal care.

Questions to ask your discharge planning team

The process of planning for discharge can be overwhelming and so we have a number of questions to ensure you are prepared for the next steps. Some of these include:

• What can I expect after hospital discharge?
• What should I be concerned about – are there signs that I will need additional support?
• Will we get access to care and home and who will pay for this support?
• Where can I access advice?
• Am I fully aware of what happens next?
• Will we receive additional support if my family member has dementia (see What are the early signs of dementia?)

If you would like more information about hospital discharge planning, or access to services, you can contact our team of experts today on (03) 8785 0999.