Overstay from a nursing perspective

The Overstay project is a good example of Collaborative Care in action: teams are establishing and building respectful and trusting working relationships, understanding roles and taking into account what each individual who is receiving care wants and needs and working together on a shared goal.

So what is nursing's role in this collaborative team?

"It's quite an integral part," says Mary Anne Lynch, Program Director, WRHA Medicine Program and Program Director Grace Hospital Medicine Program. "When a person is admitted, a nurse completes a nursing assessment - which typically focuses on physiologic mode. We've added an additional assessment that puts a focus on discharge planning and how a person is managing in the community, including highlighting potential discharge concerns."

Once the nursing assessment is complete, a discharge plan can be developed. Consults to other team members can be generated based on the nurse's assessment. Other disciplines on the health care unit team can use the information gathered and begin working toward a shared discharge plan based on a shared goals. The goal? To develop a plan that answers this question: What does this person need to go home safely?

When the process was being developed, it's a question that the nurse educator posed that helped the nursing team refocus on discharge planning and planning for home from the time a person is first admitted. Working towards the goal of discharge is a goal of care.

"I think the reason it's so successful is that we're starting with asking the right questions," says Lynch. "The team was involved in developing the questions that were needed, at least initially, to know about this person in order to support and work together on a discharge plan and together, move the plan forward."

The questions

Yes or no answers are required for most of the following questions:

  1. Is the person alert and orientated (X3) and appropriate in conversation?
  2. Is the person free of falls in the last six months?
  3. Was the person able to mobilize independently with or without gait aid prior to admission?
  4. Is the person currently managing independently or do they have supports for self care, toileting, transfers, groceries, cleaning, laundry, meal preparation, medication and transportation?
  5. Is the person and family/support confident that the person can be discharged to their current living situation?
  6. You wake up in the middle of the night and smell smoke in your home. What do you do?