Cluster 3: Major Influences on the Discharge Plan and the Supports for the Patient Post Discharge

These functions represent the processes that influence the precision and timeliness of the discharge plan and organising any patient supports required for discharge. These include the process of engaging with the patient, the model of care, and the prescription of the formal supports that the patient will require for discharge. Figure 9.5 illustrates this cluster.

To Engage the Patient

Engaging the patient is one of the controlling functions and the most important factor for enabling a timely discharge for the patient. Stakeholders include the patient/

famiIy/carer/guardian and their buy-in or engagement with the rehabilitation process and identified placement. Without buy-in from these stakeholders the information required for discharge can be inaccurate, or the process can be slowed or even stalled.

To Prescribe the Formal Supports

Prescribing the formal supports for the patient is a complex process and is identified as part of the assessment process. It includes assessing the patient’s eligibility and/or suitability for external supports such as the TCP and My Aged Care packages. It may involve aged care assessments and assessment for residential care placement. The patient’s stay in hospital is dependent on the process for assessing and organising formal external supports.

To Follow the Model of Care

Another control for discharge planning is that the team will follow a model of care that is individualised and person-centric. The entire team is cognisant that they are all striving towards discharge. The model of care influences the entire patient journey, from admission to discharge. There were also comments that an increasing number of older people are presenting acutely unwell with more cognitive impairment, frailer and with less supports. This has placed more pressure on the staff and the model of care.

Cluster 4: Readying the Patient for Discharge

These are the functions that are crucial to getting the patient ready for discharge. They are illustrated in Figure 9.6.

 
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