Dialogue Volume 14 Issue 4 2018 | Page 42

PRACTICE PARTNER Recommendations: 42   Hospitals and community health-care providers should convene interdis- ciplinary teams to review discharge plans for complex patients who will require home care services to continue treatment in the community. These plans should: requirements of dosing and monitor- ing prior to discharge. Alternative treatments or delayed discharge may be necessary in the interest of patient safety; and • E  nsure that community care prac- titioners and patients are provided with contact information for post- discharge management questions (e.g., discharging physician, hospital pharmacist, etc.). • Assess medication regimens prior to discharge to determine if, less compli- cated treatment plans are available or possible; • Ensure that the most responsible primary care provider (e.g., physician, nurse practitioner, etc.) is identified and contacted prior to discharge and has received detailed information on follow-up requirements, including laboratory monitoring; 2   Hospitals should work with Com- munity Care Access Centres and other community providers to develop crite- ria for acceptance of patients receiving complex medication therapies, such as intravenous antibiotics requiring monitoring. • Ensure that the roles and responsibili- ties of the post-discharge care provid- ers are firmly outlined and that the community care providers can accept and fulfill the roles demanded; 3 • Assess the ability of home care pro- viders to adhere to the precise time  Primary care providers should develop standardized processes to proactively follow up with patients discharged from hospital on complex treatments. This would include identifying areas where assistance may be required (e.g., dose adjustments) and clarify where, and how, to access assistance. DIALOGUE ISSUE 4, 2018 MD 1