Collaborative Discharge Planning
Misunderstanding of roles and responsibilities is a key issue faced by many teams during complex discharge planning. The involvement of many different stakeholders can lead to confusion, particularly when multiple tasks are being completed at the same time. It is important to always define roles and responsibilities of each stakeholder, and clarify these throughout the discharge process. Regular meetings and the circulation of meeting minutes enables all stakeholders to receive updates and clear actions. Having these in writing promotes accountability and prevents progress from stalling. Clear responsibilities and actions will also ensure NDIS funded stakeholders such as support coordinators can use their available hours in the most efficient and effective manner.
Top Tips and Tricks
- Don’t assume a support coordinator has worked with a hospital team before.
- Roles and responsibilities can differ between hospitals. Always take the time to explain yours.
- Frequent, short meetings reduce the need for complex long email chains, and are more effective than a single 90-minute meeting.
Case Study
Mei was admitted to hospital with significant functional decline as a result of early onset Alzheimer’s disease. Her multidisciplinary team included a neurologist, occupational therapist, social worker, support coordinator, behaviour support practitioner and family members. Weekly meetings of 15-30 minutes were arranged to share updates on progress toward discharge, and enabled stakeholders to share ideas and concerns in a timely way. These meetings were chaired by the hospital social worker, who was also responsible for ensuring actions and tasks were assigned during the meeting, and documented on an action log with time frames. Once the discharge date was confirmed, the occupational therapist (OT) was responsible for arranging hire equipment, the support coordinator ensured all community supports were in place prior to discharge, and the behaviour support practitioner arranged education of Supported Independent Living (SIL) support staff prior to Mei transitioning to their care.View the PDF version of the Collaborative Discharge Planning resource: View PDF