Client-Centred Rehabilitation - Arthritis Community Research ...

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abrupt and left them feeling isolated and
alone.
“But that transition period is not
really a transition. You are just sort
of dropped like a rock and then
you’re out there to fend for yourself
and that’s really hard” ABI #3
“then you’re out the door and you’re
on your own” SCI #3
Many felt that the responsibility of the
service seemed to end once the client was
out the door. The client’s needs post
discharge were often ignored.
“…post discharge needs which don’t
seem to be the mandate of the
institution” SCI #2
“I was never asked once…if I even
needed home care. No one even ever
asked…if I needed any help.”
PTPART #1
“the negative aspect of it was there
was no thought about the day when I
was released about what I needed to
have when I went home” HIPKNEE
This lack of preparation for discharge
contributed to feelings of fear of leaving
hospital.
“before I left I was scared I was
scared to leave. I was telling
everyone- Don’t kick me out! Don’t
kick me out!” COPD #3
“Right before discharge I was
deathly afraid to leave because
everything was set up for me [in
rehab hospital]” SCI #3
Ongoing contact after discharge
A common theme was the need for an
ongoing resource or contact while in the
community. Many clients talked about the
importance of feeling that they had someone
to call to provide advice or support or
further rehabilitation once they were in the
community. For some, this support came
from community organizations such as
disease specific organizations. Others were
affiliated with rehabilitation programs that
provided this ongoing linkage.
“I said yeah I have been waiting
nearly three months. He says you
shouldn’t have done that, you’re a
patient here. When you need us, you
phone. Well I said I didn’t know
that” COPD #1
In order to make the transition between
services better a number of suggestions were
made by the participants. The transition
should:
♦ be appropriate to the post discharge
needs of the client
♦ coordinated by a social worker,
customer service representative, or
case worker
♦ preplanned
♦ discussed by all team members
Help navigating the system
Many participants mentioned the need for
help and direction in navigating the system.
Clients would like someone to help with
transitions but often they are left to do this
on their own.
“I would like to see still that the
transition process between care,
between hospitals or what ever it
would be great if I had a case worker