Social Work/Discharge Planning

Social Work/Discharge Planning (SW/DCP) staff assists in the coordination of a patient’s discharge by collaborating with the patient, family, multidisciplinary health care team and North East Community Care Access Centre (NECCAC) Care Coordinators.

SW/DCP assists in the early identification and assessment of patient’s needs, through high risk screening and psychosocial assessments. Staff assist in the implementation of timely discharge plans that ensures the patient continuity of care and effective use of hospital and community resources.

As the patient’s treatment in hospital progresses, the SW/DCP will work with the patient/family and/or caregiver to support a successful transition back home.

SW/DCP staff helps to prepare the support that the patient may need in the community to return home safely.

Some supports that patients may need at home include:

• Nursing, therapy and personal care services through CCAC
• Day programs, meal programs, transportation, and housekeeping services provided by community agencies
• Assessment and planning for hospital to home
• Services that can be paid for privately

Home Health Care Services

In order to avoid unnecessary home visits, please tell your nurse upon admission if you are on the Home Care Program. The Home Care case manager, from The North East Community Care Access Centre (NECCAC), can then be notified to put your services on hold while in hospital. The hospital case manager will follow your progress and will meet with you prior to discharge to reassess your needs and resume your services at home.

If you feel you will require help while at home, ask your nurse to have the Discharge Planner come and see you. The Discharge Planner will assess your needs and refer you to the Home Care Program if you qualify. Should you require any other assistance with discharge planning (for example, application to a long-term care facility or community program), please ask your nurse to have the Discharge Planner see you.