Discharge planning: Social workers smooth transitions
When Tera Thomas, LSW, meets new residents at the transitional care neighborhood in The Lutheran Home: Belle Plaine, she’s already thinking about the day they’ll leave. Tera is a licensed social worker, and part of her job is discharge planning — a process to determine what a resident needs for a smooth transition from one level of care to another. Therapy, social work and nursing collaborate with the resident and family when planning for a discharge, whether that’s back to the resident’s home or to a new home.
“Discharge planning starts on the day of admission by figuring out where the resident was living prior, what tasks of daily living they were able to do prior, discussing the resident’s goals for discharge, therapies assessing what tasks of daily living the resident is able to complete at admission and setting goals from there to work toward the discharge plan of care,” Tera said.
Transitional care provides short-term rehabilitative care that helps people recover, gain strength and return to their regular routine or to a new routine with additional help. Recovery and rehab can take anywhere from two weeks to a year, depending on the diagnosis, motivation and acute issues that arise during rehab.
“We often see residents and family come in stating ‘the doctor at the hospital said I would be here for a few days and then go home.’ This length of stay is accurate for some residents. However, not for the majority, so it is helpful to keep in mind this is an estimated length of stay,” Tera said. “Most residents are anxious to get home, and it’s our goal to get them there as soon as possible, at the same time ensuring we have done everything we can to make the resident’s discharge successful.”
Discharge planning is important because it assists in a smooth and safe transition for the resident. It is helpful for friends and family to be a part of this process to help describe what the resident’s daily routine looked like prior to admission. Friends and family may have different concerns when planning of discharge.
“Being aware of those concerns is helpful in ensuring a safe discharge,” Tera said.
March is Social Work Month. Social workers stand up for millions of people every day, including people who are experiencing devastating illnesses and mental health crises, our veterans, children, families and communities. Celebrate Social Work Month by visiting The Lutheran Home Association on Facebook to share words of encouragement for social workers.
Our transitional care neighborhood serves more than seniors: Come see us to speed your recovery following hospitalization from major surgery, significant injury or emergency trauma at any age! Our excellent short-term rehabilitative care will get you back on your feet fast.