Upon discharge from a hospital, patients requiring further treatment at home often encounter unexpected financial, legal, and administrative challenges concerning their medical care. Proper coordination of all these needs is essential as it mitigates legal and financial shortfalls and, most importantly, ensures continuity and uninterrupted medical care. Conversely, poor coordination at discharge can lead to inefficient use of resources, negatively affect patients’ health, and possibly even lead to re-hospitalization if a treatment protocol is interrupted or not followed. Therefore, health Bound Health Network prides itself in providing comprehensive services to patients once discharged from the hospital.
COMMUNITY REINTEGRATION PROGRAM
Our Community Reintegration Program oversees all the details and logistics that occur during a transition out of the 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 before 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 improve their safety and ensure their speedy recovery. In addition, the program coordinates all the needs of patients and 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 discharging from one level of care to the next can enroll—for instance, individuals discharging from a hospital to a long-term care facility or hospital to their home.
This care program has some exclusion criteria, which are significant red flags that may prevent the individual from being eligible to participate in this program. Please consult a healthcare practitioner or contact us to confirm eligibility.
WHAT CAN I EXPECT ON MY FIRST VISIT
Our Case Managers or Occupational Therapists from Health Bound Health Network visit patients in hospitals and liaise with hospital staff, including nurses, social workers, and managers. In addition, they facilitate the transition to home or other health care facilities. This process includes planning safe and convenient transportation needs of the patient after discharge, as well as providing assistive devices and home modifications to make the transition from hospital to home more painless and convenient. We will also help you navigate your funding options, what benefits are available for you, and how to apply for them.
Case management helps health care professionals and patients coordinate all parties involved in the care of a person, manage health care matters, and all related administrative issues. The case management process involves the client, the family, an interdisciplinary healthcare team, insurance companies, and legal representatives. It ensures high quality of care and the continuity and assurance of proper and timely medical interventions.
Our managers liaise with occupational therapists, physiotherapists, chiropractors, psychologists, neuropsychologists, and ENT to coordinate care delivery for patients after discharge. Case managers monitor intervention outcomes and overall client progress. They evaluate the success of the care plan 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 before patients’ discharge from the hospital and make sure that appropriate home modifications are completed. Additionally, we offer home healthcare for our patients who cannot attend our locations due to 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 offered by PSWs is broad and depends on each patient’s unique needs. For example, 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 support required by each 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 care costs and establishes rehabilitative goals while coordinating with future care providers to ensure continued care and facilitate recovery.
OTHER SERVICES AVAILABLE AS PART OF THE COMMUNITY REINTEGRATION PROGRAM
- Home Modifications
- Vehicle Modifications
- Equipment Prescriptions
- Functional Cognitive Assessments and Retraining
- Cognitive Behavioural Therapy
- Transportation Service Arrangement
- Vocational Assessment and Reintegration Program
- Wheelchair Prescriptions (Through ADP and private financing)
- Activities of Daily Living (ADL) assessments and retraining
- Return to Work Program (Including work-site and ergonomic assessments, and Functional Abilities Evaluations)