Discharge & Communication

Discharge Planning and Community Assessment

• Key Objectives:

  • Discuss various types of community-based health care.

  • Describe various vulnerable populations.

  • List interview questions to determine the needs for community-based health care.

• Case Study: Delilah Smith

  • 75-year-old female with a left hip fracture requiring a total hip replacement.

  • Past medical history includes dementia; family must consent for surgery.

  • Role of the case manager includes performing assessments to identify discharge needs.

  • Discharge planning begins as soon as the patient is admitted to the healthcare facility.

Components of Discharge Planning:

• Purpose: To ensure a smooth transition from hospital to home or another care setting.

• Essential components include:

• Assessing strengths and limitations of the patient.

• Implementing and coordinating the care plan.

• Consider resources available to the patient.

• Formal discharge plan creation, setting goals with the patient.

Interaction with Healthcare Team:

• After initial assessment, the nurse case manager collaborates with the attending physician to align on discharge needs.

• Other team members may include physical therapists, social workers, and home care nurses.

Assessment Factors:

• Health data: Recent medical history and current health conditions.

• Personal data: Patient's demographics and support systems.

• Caregivers: Availability and capability of caregivers post-discharge.

• Environment: Assessing the home for safety and accessibility.

• Financial and support resources: Understanding patient's ability to afford care and access to support services.

• Engagement of Family and Caregivers:

  • Involving family is critical for successful post-discharge recovery.

  • Address questions about roles, financial aspects, and any special equipment needed.

• Home Environment Assessment:

  • Important to assess safety features within the home, including:

    • Fall risks (e.g., rugs, stairs).

    • Accessibility of bathrooms and kitchens.

    • Emergency response systems (e.g., call buttons).

• Community-Based Health Care:

  • Definition: Health care delivered in a non-hospital setting aimed at managing conditions and promoting health within the community.

  • Role of community-based nurses includes:

  • Providing education and support to patients and families.

  • Coordinating care with other community resources.

  • Facilitating follow-up assessments and interventions.

• Community-Based Settings Include:

  • Public Health Departments

  • Senior Centers

  • School-Based Health Centers

  • Outpatient Rehabilitation Centers

  • Mobile Health Clinics

  • Industrial Environments

  • Homeless Shelters

  • Home Health Agencies

  • Urgent Care Centers

  • Same-Day Surgical Centers

  • Client’s Homes

  • Faith-Based Health Initiatives

• Ambulatory Care Settings Responsibilities:

  • Include physician offices, outpatient services, and diagnostic testing.

  • Focus on outpatient care:

  • Conduct comprehensive health histories.

  • Perform physical assessments and provide education.

  • Manage referrals to specialists.

• Vulnerable Populations:

  • Groups facing barriers in health care access due to:

  • Ethnic background

  • Cultural differences

  • Economic status

  • Geographic location

  • Health conditions

  • Specific examples include:

  • People with disabilities

  • Those with chronic conditions and mental health issues

  • Cultural, racial, and ethnic minorities

  • Individuals experiencing poverty and homelessness

  • Undocumented immigrants

  • Women, children, older adults

  • Residents of rural areas and those with limited English proficiency