Discharge Planning

Discharge planning is an important part of any hospital admission. It plays an important role in ensuring a smooth move from hospital to home. This is achieved by making sure that appropriate clinical and community based support services are in place if required.

There are a number of people that can help plan your discharge:

You and your family or carer(s) can alert us if your circumstances are such that you may need additional support in the community
Your treating doctor can help identify any special requirements you may have
Nursing and Allied Health staff may help identify services that you may require
Care Coordinators can provide an assessment and arrange any services needed to support you at home immediately after discharge
Hospitals are responsible for making sure all issues that may affect your care after discharge are addressed before you leave the hospital

It is vital that any special needs following discharge are identified early so that the appropriate discharge plans can be made. We encourage patients to discuss any issues with the health care team. These issues may be present for individuals who:

Live alone
Are responsible for another person e.g. Frail partner, young children
Used community services prior to admission to hospital e.g. Meal on Wheels, community nurses
Require assistance to care for yourself e.g. showering

It is important that you consider all available options for care at home if your care needs have altered. Please note: Community services are not always readily available and not all patients are eligible for funded services

Discharge Planning Checklist

These are the major factors to be considered in discharge planning. It is important for you to discuss the following with the hospital staff during your stay in hospital.
• Your expected date of discharge – this will help you plan your return home
• Inform the hospital of your living arrangements – e.g. do you live alone, is there someone who can assist you when you go home, what services you currently receive, are you the carer for someone in your home
• Expectations regarding your recovery and how long it will take to recover
• Any possible restrictions on your activities e.g. lifting, driving a car
• Your ability to cope at home either with or without a carer needs to be considered carefully – do you need to go to a nursing home or will you require community support services such as assistance with medication or cleaning
• Any equipment requirements to assist in your recovery and independence

Care Coordinators

Care Coordinators are available to assess your needs and to make arrangements for additional community support services if required. In some instances, the most appropriate care may involve admission to a nursing home or hostel (residential care). We recognise that this can be a major, and at times, difficult decision.

The Care Coordinator will guide you through the application process for residential care for either nursing home or hostel accommodation. They will provide you with information and advice. It is the responsible of the patient/family to locate a residential care facility bed. A copy of the “Five Steps” booklet including the asset assessment forms is available from the Care Coordinator.

Care Coordination at Greenslopes Private Hospital is available to all patients and their families throughout the patient’s hospital stay. Care Coordinators are available during normal business hours from Monday to Friday.

If you are concerned about your ability to cope at home please discuss your needs with your doctor or nurse who will then make a referral to the Care Coordinator for you.

If services have been arranged for you and you have encountered a problem with the service please contact the service provider directly. The contact details may be obtained from the Allied Health Assistant - Discharge on (07) 3394 7538.

Community Nursing, Home Help and Personal Care Services

Community Services are provided by a number of different organisations, many of whom have been providing this service for many years.

Home and Community Care (HACC) services are community services funded by the Commonwealth and State Government and are accessible for frail older people over 65 years, people with disabilities and their carers. The HACC program can provide domestic assistance, personal care, food services, community respite, transport and some home maintenance. There are fees associated with HACC services. However if you are concerned about your financial circumstance please let us know - the focus of HACC is to ensure that those who are eligible receive the support they require regardless of their income.

If you are not eligible for a HACC funded service or they have not been able to accept your referral (HACC services are limited), you may need to access your services under a “user pays” model from a service provider.

For eligible veterans and war widows a HACC funded service is offered by the Department of Veterans’ Affairs. The Veteran’s Home Care service offers domestic assistance, garden maintenance and respite care to entitled veterans and war widows. There is a small charge for domestic assistance and garden maintenance.

Greenslopes Private Hospital Part of Ramsay Health Care

Discharge Planning

Greenslopes Private Hospital

Part of Ramsay Health Care