39 2.4.7 Hospital Repatriation

Transition back to LTC after hospital admission is HIGH risk due to:

• New baseline
• Persisting delirium and/or further cognitive decline
• Reduced mobility
• Medication changes
• Changes in diet texture
• Enhanced care needs
• Things to consider prior to discharge:
• Early planning while in hospital
• Open lines of communication between hospital and LTC
• Engage community partners

Strategies to improve transitions/repatriation

Creating/Using a checklist with relevant information:

• Admitting diagnosis
• Current condition
• Relevant consultation during the course of admission
• Relevant laboratory and Diagnostic findings
• Any specific care needs required including
  • Changes in mobility status
  • Changes in dietary needs
  • Wound care needs
  • Changes in care plan