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Recovery Intro & Links
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Prior to admission to the Burn and Plastics Unit, a patient may have spent days to weeks in an intensive care unit, intubated and sedated — unaware of the magnitude of their injuries. Social workers are keenly aware of the contributions made by friends and family members to a patient's physical, social, emotional and cultural well-being — not just during the hospital stay, but after discharge from the hospital. The Social Worker on the Burn Unit meets with family members early on in the admission process to provide emotional support, practical assistance, resource counselling and a variety of other services to families experiencing the crisis of traumatic injury. Often, the patient is unable to speak for themselves. In this case, the social worker meets with the patient's family and significant others to learn about the patient and who/what represents the support systems in their life. These support systems can be anything or anyone that helps the patient function on a daily basis. Each of us has support systems to some degree. For instance, we have "informal" support systems through our family, friends and neighbours and "formal" support systems through services, programs, agencies and institutions within our neighbourhoods and communities. For example, meal programs, home care nursing, home support workers, the workplace and places of worship can all be considered formal supports. Other support systems come in form of mechanical or technical aids such as wheelchairs, bathroom equipment, TTY for individuals with special needs and emergency alert systems. We all rely on a combination of formal, informal and mechanical support systems to make our lives independent, safe, interesting and fulfilling. These support systems help us live life the best we can. Knowing who and what the patient considers support systems upon their admission to the Burn and Plastics Unit helps the social worker link the patient to other valuable services, resources, and programs in their community in order to ease the transition from hospital to home in the future. It is important to bear in mind that support systems change over time and are influenced by many factors such as current needs, lifestyle, health, age and even geographic location. The Burn and Plastics Unit Social Worker can help patients and family members identify support systems and discuss how to get the support services they need. Family and Team Meetings Family and team meetings can be arranged by the social worker at any point during a patient's hospital stay. These conferences may be requested by the patient, family members, significant others, or by health care team members. Meetings can be arranged, for instance, when patients are dealing with complex and complicated medical treatments, conflicts among choices for care, end-of-life issues, when multiple services are involved, and for discharge planning purposes. Family and team meetings present an opportunity for the patient and family to formally meet in one space with the health care team to address any outstanding concerns. Patients and family members may seek current information about the medical condition of the patient, or to direct questions to specific health care providers. In addition, the patient and family members may request updates, progress reports and ideas from the team about future care plans. The general aim of family and team conferences is to share information, listen and respond to concerns, set plans or timelines for certain actions and to identify tasks that need follow up. Once a request has been made for a family/team conference, the social worker invites all the health care providers that need to be present and sets a time, date and meeting place with the family and patient (usually within a couple days of the request). Here are a few tips for patients and families to get the most from these meetings:
Follow-up meetings can be arranged as needed. Open communication between team members, patient and family is always encouraged. Talk to your social worker to see if a family and team meeting would be of benefit to you. Discharge Planning: What's in it for you? "You're ready to go home" says your doctor. These are words that can stir up many mixed emotions for patients and families who've spent time on the Burn and Plastics Unit. After days or weeks of being in the hospital, discharge is now imminent. In this case, the patient's wounds have healed to the point where he or she is considered medically stable and no longer requires acute care services. From a social work perspective, preparing the patient and family for discharge begins from the moment of hospital admission. Discharge planning involves working with the patient, family, and health care team to facilitate the transition of the patient out of the hospital and into the community. How is this done? The social worker meets with the patient and/or family continually throughout hospital admission to assess the patient's resources or support systems and determine their short and long-term needs. In collaboration with the physicians, nurses, physiotherapists and occupational therapists (among many others), social work assists in setting up required services to continue to care for patients in their home and community. For example, upon assessment, a patient may require home care nursing for daily wound dressing changes, bathroom equipment, a home-based occupational therapy assessment, out-patient physiotherapy, assistance with bathing or linkage to funding/financial resources at discharge. In some situations, family members may agree to learning how to perform simple wound dressing changes, how to monitor for signs of infection, where to pick up equipment and transportation for follow-up doctor appointments. The involvement of the patient, family, friends and significant others in discharge planning is highly encouraged and supported by your health care team. The social worker may meet with patients one-to-one or arrange a family/team meeting to discuss more complicated or complex discharge needs and concerns. The discharge plan has to be "doable" for both the patient and family. Social work encourages the patient and family to participate as much as possible in the decision-making process. Social work can provide emotional support and counselling to patients and families as they make the seemingly daunting transition from constant, expert care to being independent again in their own home with support systems in place. The patient remains in contact as an outpatient at the Burn and Plastics Unit. Therapists, nurses, surgeons and social work continue to track the progress of the patient's healing process and address any new concerns as they arise. The goal of discharge planning is to ensure a smooth delivery of services, continuity of care, and to ease the passage from hospital safely to home. Successful discharge planning begins at the admission stage. The health care team works with patients and family members to assess, plan, educate, co-ordinate and arrange continuing care services in the community. |
