Describing the Clusters

As discharge planning is a complex process with many functions depending on each other and interrelating, it seemed prudent to break the GEMS discharge model into sections to improve its interpretability and provide more detail within the model. The following sections provide comprehensive descriptions, including the aspect labels, of the clusters in Figure 9.2. Some of the figures include additional functions that are not from the same cluster. This allows the reader to view the dependencies and interrelationships among the relevant functions.

Cluster 1: To Prepare the Preliminary Discharge Plan

This process involves the typical activities involved in the development of the preliminary discharge plan. The process is described below and in Figure 9.3.

To Refer the Patient

A referral can be received through several methods, including electronically, fax, phone calls, or through paper in the mail. The intake nurse will screen the patient for suitability prior to the referral being given to the Intake Team to assess.

To Intake

The Intake Team hold multidisciplinary meetings Monday to Friday at 11.30 am. Acceptance can occur by medical/nursing or medical/allied health staff. As long as a medical officer is involved, the patient can be determined as suitable and accepted to the ward. The intake review and initial discharge plan is noted in an Intake Workbook.

To Admit the Patient

If the patient is suitable, they will be admitted the same day or as soon as practicable. The nurse involved in the intake assessment will document in the electronic medical

FRAM model of typical activities involved the development of the preliminary discharge plan record

FIGURE 9.3 FRAM model of typical activities involved the development of the preliminary discharge plan record. The output for the admission is the patient arriving on the ward, in readiness for a full assessment and care by all health professions.

To Do Initial Assessment

The initial assessment is typically a comprehensive assessment of the patient by all professions. It includes the comprehensive care plan, and preliminary work on supports, estimated date of discharge, and discharge destination. The medical officer will assess for medical stability before some specified discharge planning can start, for example, some age care assessments cannot be commenced while a patient is unwell. The allied health assessment includes the completion of a goal tree. The output for the initial assessment by all health professions is a completed initial assessment with goals documented in the electronic medical record, a patient board that has a goal tree updated, as well as the patient’s stability to complete rehabilitation. This is all information used in the compilation of the initial discharge plan.

To Provide Allied Health Service/To Provide Nursing Care/To Do Medical Ward Round/Review

Each health profession will provide care and treatment for the patient and document in the electronic medical record. This information will contribute to the preparation of the discharge plan.

To Do Ongoing Assessment

Throughout the patient’s admission, each health professional will review their assessment and update the discharge plan based on any changes to the patient’s circumstances or condition.

To Identify the Discharge Plan

The discharge plan is formulated once the patient has been admitted to the ward. Staff will engage with the patient, complete an initial assessment of the patient’s stability to undertake a rehabilitation programme. All health professions will complete an initial assessment of the patient’s goals and document these in the electronic medical record and on a goal tree located in the patient’s room. Formal supports, such as referral for Aged Care packages will also be discussed and considered. The initial assessments and comprehensive care plans will be discussed at the weekly case conference. Several outputs occur as a result of the case conference. After the case conference, the patient or their carer will confirm their agreement with the preliminary discharge plan. The output for this function is the estimated discharge date and preliminary discharge plan documented electronically. The information from this function will be utilised by staff when they are organising any supports that the patient may require for discharge.

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