Question

How can we stay involved in case of a hospital admission of one of our clients, and how to secure continuity?

Problem description

Once a client is hospitalised,  direction is taken over from both the client and the case manager.  The hospital team makes decisions, most of the time without paying much attention to the trajectory previously covered by  the client and the case manager.

During hospital treatment, too little attention is paid to the daily life context.  There is little communication with the case manager

Impact - effect

Client is removed from his environment, then treated and re-oriented back to his environment.  When the network of the client is not much involved during the hospital treatment, we notice the possible occurrence of a relapse at short notice.  Often the case manager must restart a trajectory instead of continuing one

To do

To do : it’s important that the case manager should stay involved during hospitalisation, allowing him to continue as key-worker or reference person for the client.  We need a change of mentality, a rethink, in the residential setting.  And to make proper arrangements, and clear communication lines

Theme

Hospitalisation

Topic

Role of the mobile team when the user is admitted to hospital: inreach in residential units, early discharge

Reference -  contact

Geert Jacques, Sofie Pringels, Annelies Remaut

Mobile team

2B

Project

Zuid West-Vlaanderen

Intership abroad - place

Noord-Holland-Noord

Date

November 2013