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Patient gets sick. Patient goes to the hospital. Patient goes home.
From afar, the above formula sounds like a straightforward approach to the daily business of hospitals. And for the vast majority of patients, it applies.
But patients are people and every individual has a unique set of circumstances – many of which directly affect how soon, and where, they can be discharged when ready to leave the hospital.
Enter the occupational therapist (OT) who, along with their Allied Health colleagues, work collaboratively with a patient's medical team to develop a discharge plan once a patient is medically stable.
October is OT Month, when we celebrate and promote the role that Occupational Therapists and Occupational Therapy Assistants (OTAs) play within our multidisciplinary teams across UHN.
Their expertise is an important piece in a patient being discharged and doing well after a hospital stay.
"My work focuses on improving a patient's functional status and optimizing their safety following an acute care stay," explains Mariana Camargo, an OT at Toronto Western Hospital (TW).
"We assess a patient's ability to carry out day-to-day tasks like getting dressed, toileting, managing their medications, as well as potential safety risks. All this information is important to decide when and where to discharge a patient and what services are needed to support our patients in the community."
Those who believe a patient "just returns" to where they were before they came to the hospital might be curious to understand why "where" a patient goes after their hospital stay matters.
It's a clue as to how crucial the role of an OT has become in discharge planning in recent years.
Challenged to 'get creative' to find services for patients
In most cases, if a patient doesn't go home after their hospital stay, they usually transition to another facility such as rehabilitation or long-term care. But there is also a group of patients for whom getting sick and going to the hospital reveals that their current living circumstances are insufficient to support their recovery once they're ready to leave.
"For example, in our General Internal Medicine (GIM) units, we often see elderly patients with various medical conditions who are quite isolated and vulnerable in their communities," says Mariana. "We want to ensure they receive the appropriate community supports to keep them out of an acute care hospital environment, and they are thriving in their own community setting."
It's a medical Catch-22: a patient's care team only wants to discharge a patient if they have what they need to support their well-being. On the other hand, once a patient no longer needs acute care, a hospital is not the best environment for them.
This challenge adds another layer to the OT role where not only are they assessing whether a patient is ready for discharge, but also navigating the healthcare system to find services to support them.
"I didn't really anticipate this part of the job when I was training to become an OT, but it has challenged us to get creative and find the service or even combination of services available to help our patients," says Mariana, who has additional insight into patient transitions from previously working as a Home and Community Care Coordinator with the Central Local Health Integration Network (Central-LHIN).
As part of discharge planning for this particular patient population, Mariana and her colleagues work with community partners to find services available that will best support patients. Among these are home care services, such as personal care support and case management through the LHINs.
The hospital staff also work with outreach programs, including Crisis Outreach Services for Seniors, which provide a range of services from transitional housing units to psychogeriatric case management that helps find medical, financial, emotional and recreational resources and supports to help seniors remain as independent as possible.
It's a skill that's likely to be in increasing demand as the country's population ages.
"As an OT in acute care, I am continuously challenged to support the changing needs of our diverse population as every patient we see comes in with unique circumstances and care needs," Mariana says.
"I feel privileged every day to be in this role, helping our patients and their families navigate and transition from hospital to community care."