Health practitioners can boost quality of life, safety, and promote successful discharge into the community.
Consider your patient's current situation and likely trajectory.
Allied health
The following list outlines various allied health team members and their contributions to discharge planning:
Pharmacy
- Review of medicines.
- Identification of medicines that are no longer beneficial or appropriate for the patient, are not desired by the patient, or both.
- Summary of discharge medicines.
- Coaching of patient and carer about discharge medicines.
Occupational therapy
- Strategies to conserve energy and achieve important personal goals.
- Relaxation (contributing to pain relief).
- Organisation of equipment, such as pressure care devices and an electric bed.
- Home assessment.
Physiotherapy
- Improvement and preservation of strength.
- Review of airway clearance and breathing exercises.
- Relief of musculoskeletal pain.
- Mobility and walking aids.
- Home assessment.
Speech therapy
- Management of impaired function, such as coughing with fluids.
Dietitian
- Strategies to minimise loss of weight and increase energy.
- Strategies to prevent or relieve nausea and constipation.
Social work
Assistance with:
- complex grief
- children
- advance care planning, powers of attorney and wills
- finances and government benefits
- housing
- MyAgedCare and the National Disability Insurance Scheme.
Pastoral and spiritual care
- Listening and companionship.
- Support with emotional and spiritual concerns.
- Strategies to understand and manage feelings arising from the diagnosis and prognosis.
- Help in thinking about and arranging the funeral.
General practitioners
There is a lot you can do to support the general practitioner’s care of your patient after discharge home.
Imagine you are Joe’s general practitioner. Joe has a terminal illness and the last time you saw him was when he had difficult symptoms and you sent him to hospital. Six weeks later Joe’s wife calls you and says that Joe came home yesterday and now feels terrible. What should they do? You currently:
- don't have a discharge summary
- have no idea what happened during Joe's hospital admission
- don't see many people with end of life illness
- have an overflowing waiting room.
How to support the general practitioner
You can support the general practitioner and promote successful discharge home by:
- calling them to discuss complexities and changes
- informing them of any referrals, for example to community palliative care
- giving them a name and phone number of an appropriate person in the treating team
- recommending HealthPathways, an online portal designed for general practitioners. The site holds local and relevant information about medical conditions, symptom outlines and management options, and information about how to refer to the most appropriate local services.
- advising them of End of Life Directions for Aged Care (ELDAC) if the patient is going to a residential aged care facility
- expediting the discharge summary
- communicating relevant information from the acute resuscitation plan to inform advance care planning.
In the meantime, send the general practitioner:
- results of the most recent investigations
- summary of family meetings
- palliative care intentions and expected outcomes
- medical power of attorney
- coronial status.
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