Discharge planning at NorthBay is truly a collaborative effort and it involves a multi-disciplinary approach. It’s a process that usually starts when a patient comes to the Same Day Center for pre-admission tests, and the evaluation continues all through their hospital stay.
As soon as a patient arrives at NorthBay Medical Center, Tina Simon, R.N., starts planning for the day when they go home. As an inpatient case manager, “discharge is something I start working on the minute the patient comes in through the door.”
It’s not that the hospital is in a particular hurry to get patients on their way; it’s more about making sure that when they are discharged, it’s to a place that is best prepared to meet their post-surgical needs.
Discharge planning at NorthBay is truly a collaborative effort, Simon stresses, and it involves a multi-disciplinary approach. It’s a process that usually starts when a patient comes to the Same Day Center for pre-admission tests, and the evaluation continues all through their hospital stay.
“I try to meet with the patient as early as possible, before surgery even, to introduce myself and evaluate their home history,” Simon says. Is there support or help available from family or friends, for at least the first week after discharge? If not, perhaps discharge plans need to be made to a skilled nursing facility, until the patient is ready for independent living again. Is the patient diabetic or on dialysis? That will trigger special post-discharge needs, such as nutrition counseling or out-patient treatment. Simon is also in close communication with Jamie Chohon, acute care nurse practitioner, who is the case manager for all cardiovascular surgical cases.
Since each patient’s post-surgical needs and home situations are different, determining what’s best for them requires a coordinated effort between the patient, their family and friends, the cardiologist and nursing staff, Simon explains. “Some patients have plenty of help from family and friends; others may have little support or even be homeless,” in which case they would be referred to Social Services. “We discuss the options available and re-evaluate them as the patient recovers, and make any necessary adjustments.”
Simon has been a nurse at NorthBay for 23 years, and has spent the past five years in case management. Working with cardiovascular patients offers her a “new clinical picture” with a pleasant surprise.
“I find my patients are recovering quickly—within three to four days—and before you know it, they’re up and ambulatory. It has changed my expectations; I thought I would have more time to plan for their discharge!” she says. “I am also impressed with the level of care and attention our patients are getting; there is always someone with them. It’s a very supportive team, and that is good for our patients.”