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
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