Providing patient-centered enhanced discharge planning and rural transition support: Developing a local health and human services resource bank for rural communities

Abstract

Patients may have a wide range of needs when they are discharged from a regional hospital back home to a small town or rural community. Discharge planners and other staff at the regional referral hospital are seldom aware of the range of services and resources that a patient could use to facilitate their recovery close to home. Indeed, in our research, regional providers acknowledged that they lacked information about the many small towns they served in their catchment area. Patients, regional referral hospital staff, and small town providers all reported that this frequently led regional providers to refer patients to services and providers in the city. Facilitating a smooth transition from a regional referral hospital back home to a small town or rural community requires that a patient be connected with as many local resources as possible to meet the needs they have. The purpose of this practice guide is to outline how service providers can develop their own health and human services resource bank and build a catalog of resources. A complimentary document describes how to load and program a tablet computer with a resource bank