Often, patients who are ready to leave the hospital require some level of care at home. Discharge planning helps connect patients with the services they need. Patients at Thunder Bay Regional Health Sciences Centre who are returning to communities served by Dilico Anishinabek Family Care now have specialized discharge planning support.
Priscilla Sky, RN, is a Discharge Planner with Dilico, working at our Hospital. As a nurse with over 20 years’ experience, Sky has a vast knowledge of the specialized programs, services and resources available to people living in the First Nations communities of the Robinson-Superior Treaty area.
Sky meets with patients and health care providers at the Hospital to identify if any care services will be needed after discharge, such as home-based nursing care for dressing changes following surgery, IV antibiotics, or personal support. She then coordinates the care, and assists with a smooth transition from hospital to home.
The partnership between the Hospital and Dilico was initiated as an opportunity to enhance patients’ experiences and outcomes, while helping them to avoid waiting in the Hospital any longer than necessary. It is working. Patients are able to return home sooner, with the support they need.
Patient feedback has been highly positive. “People appreciate seeing a familiar face from their community, particularly from Dilico, an organization they already know,” Sky said. Patients have also expressed gratitude for the personal attention, and for the access to timely, specific service.
Dilico Anishinabek Family Care provides a range of responsive individual, family and community programs and services for the complete life journey of all Anishinabek people. Dilico cares for the welfare of children and families, physical health, the mental health and the health of the communities where Anishinabek people live by promoting wellness, preventing illness and trauma, and providing diagnosis, treatment and rehabilitation.