Selecting care supports

When transitioning from hospital to home, choosing the right care supports is an important part of ensuring that individuals with spinal cord injuries receive the ongoing care they need. This decision-making process involves considering a variety of factors to ensure that both immediate and long-term needs are met. Below are key areas to consider when selecting appropriate service providers and support workers.

Funding sources

One of the first steps in selecting care supports is securing the necessary funding. Understanding the available funding options and how they can support ongoing care will ensure a smooth transition home.

  • Secure funding early: engage with relevant funding sources as early as possible during rehabilitation.
  • Understand your options: familiarize the person and the team with available funding streams and what they cover.
  • Discuss limitations: if available funding doesn’t meet needs of the person, explore alternative resources or agencies.

Choosing a service provider

Selecting the right service provider is crucial to ensure that care needs are met consistently and effectively. The following considerations will help you assess potential service providers and support workers.

  • Training and recruitment: ensure the provider has robust training and recruitment processes to prepare staff for the person’s specific care needs.
  • Capacity and availability: assess the provider’s ability to fill shifts and meet the person’s care requirements consistently.
  • Task clarity: clearly define care tasks (e.g., bowel care) to ensure that support workers understand the specifics of each task.
  • Policies and procedures: review the provider’s policies on accessible transport and other essential supports, like disability-related health care (e.g., insulin management). 

Planning for discharge

As part of the transition from hospital to home, it is important to plan for discharge well in advance. This includes not only identifying where the person will live but ensuring the care plan is comprehensive and addresses both clinical and social needs.

  • Discharge destination: consider how the location of the person’s home might impact service availability and travel logistics.
  • Comprehensive care planning: identify the person’s goals, including community access, social activities, and work or study, and incorporate these into the care plan.
  • Support networks: identify both formal (service providers) and informal (family, friends) support options.
  • Test the care plan: where possible, trial the care plan in the hospital setting to ensure it meets the person’s needs.
  • Education and training: provide written guidance and hands-on training for support workers on essential tasks like bowel care, equipment maintenance (e.g., wheelchairs), and hoisting.
  • Community access trials: arrange for visits or passes before discharge to identify and address potential issues.
  • Transition supports: link the person to additional transition supports, like the Transitional Rehabilitation Program, for guidance as they move from hospital to home.
  • Discharge summaries: share detailed discharge summaries with the person and their service provider (with consent). These should include information on autonomic dysfunction management, musculoskeletal care, respiratory care, skin management, bowel and bladder care, and psychosocial support.

Empowering the person

Empowering people with spinal cord injuries is a key component of rehabilitation. Supporting them to take an active role in their care promotes independence and ensures that care is tailored to their needs.

  • Education: encourage the person to become knowledgeable about their injury and care needs, helping them become the ‘expert’ in managing their condition.
  • Assertiveness training: provide skills and support to help the person actively participate in directing their care, fostering shared responsibility between them and their support team.
  • Flexible planning: develop back-up plans for both good and bad days, accounting for changes in staff availability or routines, ensuring care arrangements remain flexible.