What happens when it's time to go home?
- Upon admission, our social worker reviews medical records and speaks with the patient concerning life at home before hospitalization.
- A patient care conference is held within the first 14 days with the patient, family members and/or significant others to discuss progress with therapies, medical conditions, staff interaction and any concerns the family or patient may be experiencing toward the discharge goal.
- The social worker consults with the family and the patient to install the appropriate discharge placement, such as a possible assisted living environment, or community/private duty care providers for in-home care.
- The social worker will discuss the home environment with the therapy team to decide if an in-home evaluation would benefit the patient.
- The therapist may recommend environmental modifications be made to the home.
- When the discharge date is scheduled, the social worker will work with the physician, family and the facility team to schedule home therapy, nursing care and any equipment that is needed in the home for patients to continue their road to recovery.
- A patient's release will only occur if and when the physician feels the patient is physically and mentally stable.