Cluster 2: The Resources Required for the Discharge Plan and Patient Supports Post-Discharge

This next cluster of functions involves the major staffing resources that are usually required for both the discharge plan and organising any supports that the patient requires for discharge. Each of these resources provides information for the formulation of the discharge plan and required supports. These are illustrated in Figure 9.4.

To Hold Case Review

This is an ad hoc meeting required for individual patients with complex needs. Sensitive issues that have been uncovered during assessments will be discussed. It is particularly important to discuss any legal issues that have been revealed. This information is for the treating team only and will not be discussed during the case conference.

To Hold Family Meeting

This meeting is organised by the social worker and is a crucial component of the discharge plan. There will be a pre-meeting before the family meeting to discuss the plan for the meeting. Engagement with the patient/family/carer/guardian is crucial for the rehabilitation process and identified residential placement.

To Huddle

This meeting is held on a Monday and Wednesday, and includes medical, nursing and allied health staff. This group can make the decision that the patient is ready for early discharge. At the meeting, the patient board is updated with planned family meetings, discharge destination, estimated date of discharge (EDD), and any referrals to the TCP. The electronic management system called Patient Flow Manager (PFM) is

FIGURE 9.4 FRAM model of the resources required for the discharge plan and the supports required for discharge updated but is not generally used after the huddle but will be printed out the next morning for handover.

To Hold Case Conference

The meeting is held to review the patient’s assessment, confirm patient’s capacity to consent and their medical stability, confirm supports and review timeframe for EDD and discharge destination. It is held every Thursday between 12.30 and 4.30 pm. The very first case conference for the patient will enable the formulation of a very broad description of the discharge plan with the outcomes documented in various locations, including a handover sheet, patient board, electronic system (PMF). and in the electronic medical record (i.e., EMR).

To Hold Feedback Meeting

This meeting includes nursing and allied health staff and is held on a Tuesday and Friday. The participants will discuss patients from overnight and identify if anything has affected the discharge planning. No major decisions will occur at these meetings. However, the decision to ‘stop’ a discharge will occur if the acuity of a patient has changed. For example, the patient has had a fall or a stroke overnight.