Upon discharge from a hospital patients that require further treatment at home often encounter a whole new set of unexpected financial, legal and administrative challenges with respect to their medical care. Proper coordination of all these needs is important as it mitigates legal and financial shortfalls and most importantly, ensures continuity and uninterrupted medical care. Poor coordination at discharge can lead to inefficient use of resources, can negatively affect the health of patients and possibly even lead to re-hospitalization if a treatment protocol is interrupted or not followed. Health Bound Health Network prides itself in providing comprehensive services to patients once they have been discharged from hospital.
COMMUNITY REINTEGRATION PROGRAM
Our Community Reintegration Program oversees all the details and logistics that occur during a transition out of hospital, such as ensuring that clients’ discharge location is safe and accessible for them given their limitations or injuries, ensuring that they have all necessary assistive devices/equipment prior to discharging to increase their safety and independence, and liaising with the hospital team to ensure that patients’ continuity of care is not interrupted following their discharge to increase their safety and ensure their speedy recovery. The program coordinates all the needs of patients as well as the requirements of the parties concerned with their treatment. Health Bound takes care of everything, providing patients with the peace of mind they need to recover and improve their health.
WHO CAN ENROLL
Anyone who is discharging from one level of care to the next. For instance individuals discharging from hospital to a long-term care facility, or hospital to their home.
This program of care has some exclusion criteria, which are significant red
flags that may prevent the individual from being eligible to partake in this program. Please consult a healthcare practitioner or contact us to confirm eligibility.
Case management helps health care professionals, and patients alike to coordinate all parties involved in the care of a person, manage health care matters, and all related administrative issues. The process of case management involves the client, the family, an interdisciplinary healthcare team, insurance companies and legal representatives. It ensures high quality of care, as well as the continuity and assurance of proper and timely medical interventions.
Health Bound case managers liaise with occupational therapists, physiotherapists, chiropractors, psychologists, social workers, neuropsychologists, speech language specials, ENT, and nurses to coordinate care delivery for patients after discharge. Case managers monitor intervention outcomes and overall client progress. They evaluate the success of the plan of care and make adjustments with input from all involved individuals, to help facilitate quality care and patient-centered outcomes.
Health Bound occupational therapists ensure that the home environment is assessed prior to patients’ discharge from hospital to home and make sure that appropriate home modifications are completed. Additionally, we offer home healthcare for our patients who are unable to attend our locations due to the nature of their injuries. We provide home services for Occupational Therapy, Physiotherapy, Psychological Counselling, Chiropractic Care, Rehabilitation Support Worker services, and many more.
PERSONAL ASSISTANCE PLANNING
For the more seriously injured patients, who require assistance with their normal daily activities at home after hospital discharge, Health Bound Health Network offers personal support workers who will provide the patient with personal support for everyday activities. The scope of services provided by PSWs is wide and depends on the unique needs of each patient. Our Occupational Therapists can complete an attendant care assessment and Form 1, which looks at the level of independence a person has with completing their day to day tasks, such as getting dressed or meal preparation. This assessment helps identify the number of hours and level of support required by each individual patient depending on their physical, cognitive, emotional and environmental limitations.
LIFE CARE PLANNING
Case Managers summarize the medical, educational, vocational, psychosocial, and daily living needs of the person who can function indefinitely only with professional assistance. The Case Manager also projects the long term costs of care, and establishes rehabilitative goals while coordinating future care providers in order to best assure a continued care and facilitate recovery.