[Discharge planning for home care]

Area of Science:

• Healthcare Management
• Social Work in Healthcare
• Patient Discharge Planning

Context:

• Established a dedicated department for medical social work and discharge planning at the University of Tokyo hospital.
• Recognized the need to ensure patients receive appropriate care in suitable settings post-discharge.

Purpose:

• To implement a structured discharge planning process.
• To facilitate seamless transitions for patients requiring continued care outside the hospital setting.
• To enhance the coordination of post-discharge care services.

Summary:

• The discharge planning team comprises a physician, a medical social worker, and a home care coordinator.
• The home care coordinator plays a crucial role in liaising with home nursing stations and primary care physicians.
• This coordination is vital for advancing home care services and alleviating patient anxiety regarding home-based treatment.

Impact:

• The implementation of the home care coordinator role has demonstrably increased the number of patients opting for and receiving home care.
• Improved patient transition and continuity of care leading to better health outcomes.
• Enhanced patient and family satisfaction with post-hospitalization care arrangements.