August 23, 2006 - Discharge Planners can make your move easier

Moving from one home to another is something that normally involves months of planning and preparation. When timelines are compressed and decisions have to be made under pressure, professional advice can make a world of difference.

At St. Francis Memorial, a full team is in place to help make patients’ moves as organized as possible, whether they’re going from the hospital to home or to another facility.

Leading that team is the discharge planner. The discharge planner works with physicians, nursing staff and other care providers such as physiotherapists and pharmacy, to provide guidance and advice to the patient and family. Together, they assess each patient’s abilities and needs to plan for the best possible outcome.

If placement in a long-term care facility such as Valley Manor is required, the Renfrew County Community Care Access Centre (CCAC) becomes involved and manages the necessary arrangements.

“We all work closely together as a team,” says Cathy Serran, RN, one of the discharge planners at SFMH. “Assessments of patients in the hospital are mirrored by home assessments done by CCAC staff.”

The goal is to be sure that people are making the right plans and the system is being used efficiently.

Mrs. Serran recommends that families who feel nursing home placement may be approaching should contact the CCAC. They will help families to explore the various levels of care available and encourage visits to different facilities.

Family discussions and pre-planning is beneficial rather than waiting for a crisis. “They need to go and see which facility fits their needs,” Serran says. “Often, they visit a nursing home and then realize that they’d be better suited in a retirement residence that offers a lower level of support for people who are more independent.”

The choices are complex and can be confusing to families who have not been involved in the care system. While discharge planners recommend being informed as early as possible, they note that it isn’t as simple as going on a waiting list now to ensure you’ll be covered at some point in the future if the need arises. Under current policy, if a candidate turns down a long-term bed offer, their name is taken off the list for six months (unless their condition changes). Then, if they re-apply, they go back to the bottom of the waiting list.

“You have to be very sure of your needs and situation before you complete the papers,” she says. “People who are on the list are there because they need to be there.”

Serran acknowledges that making decisions about long-term care can be difficult and overwhelming. Supporting and helping patients and families to make rational decisions at a difficult time is the focus of the discharge planner.

“We’re here to help,” she says.