Question

How to improve the evaluation of needs and problems in the home situations (for instance before discharge from hospital)?

Problem description

Situation : during a meeting there is a request of engaging the mobile team in a new case, a patient that is hospitalised for 2 ½ months.    The objectives for inclusion are: evaluate the starting up of a treatment, to work with the network that is installed during the hospitalisation, observation of the thymic state of the patient.   After this medical consultation and agreement about involving the team, an appointment is made with the patient and the referrer at the hospital unit.   Currently, we meet the patient and the team on a regular basis, that is, before discharge from hospital.

However, it would be very useful to utilise several tools to improve our work in the home situation. Tools permitting to evaluate the needs and the problems of the home situation in a better way, and getting a better understanding of the patient and his primary, secondary and tertiary network, and this before discharge from hospital

Impact - effect

Without utilising these instruments, the team could start working in the home situation using a false or inadequate image of the needs and the problems of the person.  During hospitalisation, the real problems are partially put between parenthesis.  The coordination of what is already realised in hospital and what there is still to do in the home situation, is not optimal 

To do

To do :  1) during a hospitalisation a mobile team collaborator should be involved as soon as possible; 2) working in a direct way with the needs and problems of the patient and not allowing that our perceptions will prevent this (for ex. Using ELADEB, network card, crisis plan); 3) consider the use of an electronic file, in order to improve collaboration and exchange of information and 4) planning a supervision for each mobile team member every 15 days.

We should avoid visiting the person at home before seeing him (in hospital) and to apply mainly our own vision regarding the patient’s problem instead of his own view

Hyperlink

http://www.mobileteamsconnecting.eu/bijlagen/H25%20-%20article%20CMT%20(Lausanne).pdf

Theme

Starting up and further development/deployment of mobile teams

Topic

critical success factors for starting up and further development/deployment

Reference -  contact

Christine Vitiello, assistante sociale EM Henri-Chapelle

Mobile team

2B

Project

RéSME

Intership abroad - place

Lausanne (CMT)

Date

February 2014