We can help patients make a smooth transition from the hospital to their home or residential aged care facility through comprehensive and clear discharge planning and communication.
If a patient is ready to go home with a continued need for wound dressings, talk to the patient and their family and carers about the type of dressing regime that will work for them.
Involve appropriate support services, such as home nursing, and communicate the person-centred care plan to ongoing care providers.
Having a wound increases the risk of a person becoming socially isolated and experiencing loneliness. Find out what social support the person has, and include their engagement with formal or informal supports as part of their discharge plan.
Provide a discharge summary, including the wound management plan, to the patient’s GP. Ensure the patient and their family and carer also receive a copy of the discharge summary and wound management plan.
Make referrals to allied health specialists or other services as appropriate:
- wound specialist or clinic if wound advice is required
- dietitian if malnutrition or dehydration is suspected
- podiatrist if foot care or footwear advice is needed
- physiotherapist if balance or mobility advice is needed
- speech pathologist if there are swallowing problems
- occupational therapist if patient requires specialised equipment at home.
Consider if the person needs personal care, help with other tasks of daily living or appropriate wound dressing, and refer to appropriate services.
Local services such as the council, neighbourhood house or library can link the person to local social activities.