MSH helping transition patients safely back into the community

We are familiar with the physician, nurse, physiotherapist and social worker as part of the healthcare team looking after a patient while in hospital. But what about the patient-flow coordinator?

An integral member of the dynamic clinical team, they are responsible for coordinating the discharge planning process.

Working with the inter-professional team, patients and family, they identify those patients most in need of discharge planning services and develop individualized plans to facilitate a safe, appropriate and timely discharge and transition back into the community. Getting back into the community can mean different things for different patients. The patient-flow coordinator works with patients and their families for discharge to appropriate destinations including home, rehabilitation, convalescent care, retirement homes, complex care facilities, long-term care facilities and other community placements.

Maria Easow is an alternate level of care coordinator at Markham Stouffville Hospital. She oversees patient flow for the hospital’s three sites, working with patients and their families to develop specialized discharge plans for each patient to ensure they are safely transitioned out of the hospital.

In her role, she encounters patients and their families who are concerned about being discharged. In one case, a patient and family member were worried about being discharged back home due to a safety issue. Easow worked with the family and the care team to hold the discharge until the safety concern was rectified. Easow liaised with multiple partners in the community and got the issue resolved.

“When I know a patient is ready to be discharged, it is my job to meet with them within 24 hours and work with them to identify individual discharge needs, goals and concerns,” says Easow. “I do my best to mitigate risks and ensure that patients are going back into the community safely and comfortably.”

Easow works as part of the care transitions program at the hospital. The program includes rehabilitation services, complex continuing care, alternate level of care, palliative care and hospital-to-home including the community medicine clinic.

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The goal of the care transitions program is to support patients safely transitioning out of the hospital into the community. They do this by working collaboratively with an interprofessional team of providers and allied health; having home and community services present on the units; engaging patients and their families in the discharge process; ghaving access to the hospital-to-home clinic; having discharge information getting to the patient’s family physician within 24 hours; and conducting patient discharge follow-up phone calls.

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