Our PCN recognized the need for improved communication between acute care sites (like hospitals), and primary care providers (like your family doctor). So, Dawn helped design our discharge planning program, to decrease the chances of hospital readmittance, to help in recovery, to ensure medications are prescribed and given correctly, and to prepare those required to take over the patientʼs care.
Our Discharge Planning Program provides the critical link between treatment the patient receives in hospital, and post-discharge care provided in the the Patient Medical Home (pMH).
Prior to our initiative, patients sometimes left the hospital without their family doctor being aware of the discharge. This lack of information often led to:
- duplicate effort between Alberta Health Services and pMH,
- minimal - or missing - communication, and
- faltering confidence on the part of patients that everything that could be done was being done for their health concerns.
In our current rural model, our RN attends weekly multidisciplinary discharge plans, advocating for referrals to community/outpatient services while collecting information on the patient’s plan for discharge.
The discharge plan then gets relayed from our nurse to that patient’s physician or pMH. This is where the primary care team gathers information on the anticipated discharge, and plans for community follow-up.
A patient’s primary care team may also relay pertinent information back to the acute care site via the CRPCN nurse. Once the patient is discharged, the primary care team is notified by acute care and the follow-up care can be initiated.