Discharge Planning for Home Care
To prepare for early hospital discharge and the possible need for follow-up care in the home, discharge planning begins with the patient’s admission. Several different personnel or agencies may be involved in the planning process. In hospitals, social workers or nurses may serve as the discharge planners. Some home care agencies have liaison nurses who work with discharge planners to ensure that the patient’s needs are met when he or she is released from the hospital. Professionals in ambulatory health care settings may refer patients for home care services to prevent hospitaliza-tion. Public health nurses care for patients referred for anticipa-tory guidance with high-risk families, for case finding, and for follow-up treatment (eg, patients with communicable diseases). Parish nurses may have patients referred, or they may be con-tacted directly by members of the parish community who need guidance or referrals related to physical or psychosocial health care concerns (Palmer, 2001).
The development of a comprehensive discharge plan requires collaboration with professionals at both the referring agency and the home care agency, public health agency, or other community resource. The process involves identifying the patient’s needs and developing a thorough plan to meet them. Communication with and cooperation of the patient and family are essential.
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