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Adults with a primary diagnosis of schizophrenia who are discharged from an inpatient setting have a team or provider who is accountable for communication and the coordination and delivery of a care plan that is tailored to their needs.
Transitions from hospital are important events that can introduce the risk of breakdowns in a person’s care and of crucial information being lost or miscommunicated. It is important for people with schizophrenia who are leaving hospital to have a care plan that is shared between their providers in hospital and those in the community.
Your health care professionals from the hospital should work with you to ensure all important information is transferred to your new health care professionals in the community and that you are connected to the ongoing supports that you need.
When discharging people to the community, send their care plan to their team or provider who will be accountable for coordinating, communicating, and providing their care on an ongoing basis.
Ensure systems, processes, and resources are in place for health care teams to share health information between settings, including communication platforms, standardized protocols, and tools (such as discharge planning protocols). Specifically, ensure that hospitals are able to share care plans with providers in the community once people are discharged.
Percentage of adults discharged from hospital with a primary diagnosis of schizophrenia who have their care plan made available to the receiving provider within 7 days
Denominator: total number of adults discharged from an inpatient setting after an admission for a primary diagnosis of schizophrenia who have a documented care plan
Numerator: number of people in the denominator whose care plan is made available to the receiving provider within 7 days of discharge
Data source: local data collection
Percentage of adults discharged from hospital with a primary diagnosis of schizophrenia who are discharged to homelessness
Denominator: total number of adults discharged from an inpatient setting after an admission for a primary diagnosis of schizophrenia
Numerator: number of people in the denominator who are discharged to homelessness
This process includes:
Transfer of the care plan
Provision of treatment history, including treatments that have succeeded andthose that have failed
Arrangements for housing
Arrangements for follow-up services in the community for the patient as well as any family, caregivers, and personal supports involved in their recovery
Provision of an assessment of the level of service needs (assessed using a tool or instrument such as the Level ofCare Utilization System [LOCUS]) in order to match resource intensity with care needs
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