Module 2: Direct Comprehensive Primary Care in the LTC Setting
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