Discharge Preparation Service
The discharge preparation service employs an integrated healthcare team model to ensure comprehensive discharge planning, with a strong emphasis on patient-centered care. This is accomplished through the collaborative efforts of a diverse team of professionals—including physicians, nurses, nutritionists, pharmacists, rehabilitation therapists, and social workers—who work closely with the patient’s family.
By utilizing discharge preparation plans, care management, and community resources, the service not only enhances the patient’s condition during hospitalization but also equips family members and patients with essential knowledge and skills for post-discharge care. This approach addresses the patient’s care needs and facilitates a seamless transition home or to other appropriate care facilities, serving as a bridge between acute medical care and subsequent care systems.
Introduction to the Unit
Importance of Discharge Preparation Services
The service supports patients during hospitalization by teaching them how to care for themselves or their family members, thereby alleviating anxiety related to discharge for both patients and their families. It leverages social care resources to ensure that patients receive appropriate follow-up care arrangements. This approach reduces the economic and emotional burdens on patients and their families while minimizing the need for family members to travel back and forth.
Target Audience for the Discharge Preparation Service
Inpatients who require assistance and guidance for discharge following assessment.
How to Select and Organize Post-Discharge Placement
Stop, Look, Listen – Given the patient’s condition, it is our collective responsibility to consider the needs of both the patient and their family when selecting the most appropriate care setting.
Service Items
- Develop an appropriate post-discharge care plan.
- Provide information on community care resources pertaining to home care.
- Coordinate referrals to appropriate home nursing services, long-term care facilities, or other essential care options.
- Provide assistance with referrals tailored to individual case needs, including social workers, nutritionists, rehabilitation therapists, and other professional services.
- Follow up on the care situations of discharged patients and provide healthcare consultations.
- Offer psychological and emotional support to family caregivers, along with consultations that address caregiving challenges and provide relevant information.
- Connect with Long-term Care 2.0 for discharge preparation and supportive hospital services, which include:
- Home services
- Home nursing
- Home rehabilitation
- Respite care
- Basic living aids
For inquiries, please contact the Discharge Preparation Service Office at the following phone number: 239-341-9191, extension 525226.