discharge planning and community services

discharge planning

the development of a personalised plan for a patient leaving a health service organistion

subacute inpatient care

• inpatient rehabilitation

• geriatric evaluation and management

• transitional care program

inpatient rehabilitation

• fast stream

• more intensive (approx 3hrs of therapy per day)

• capacaity for faster recovery

geriatric evaluation and management

• slow stream

• usually >65yrs (chronic or complex conditions

• multidisciplinary management and discharge planning

• aiming to maximise indepenece and quality of life

transitional care program

• >65years, 12 weeks duration, case management and low intensity therapy

• maximise function post admission and prevent admission to residential care

health independence program

• post acute care

  • short term (4 weeks) post discharge from public hospital

  • no cost to client

• ambulatory rehabilitation services

  • referred from hospital or community

  • funded via public hospital, may have co-payment

• specialist assessment services

• hospital admission risk program

community services

• national disability insurance scheme (NDIS)

• aged care assessment team/service (ACAT/S)

• commonwealth home support program

• home care packages

  • for older ages

considerations for D/c planning

• pre-morbid function

• living circumstances

• current function

• pre-discharge preparation

• does your patient need ongoing physiotherapy

ISBAR

• introduce

• situate

• background

• assess

• recommend