Discharge Planning
It is the expectation that each individual will maximize his or her use of the therapeutic program and will be returned to outpatient care once a suitable aftercare plan is arranged. The social worker's chief responsibility is to coordinate the discharge planning for the individual. This process begins at the time of admission, and includes the following elements: individual discharge planning meetings with the patient, conducting the pre-discharge group, coordinating the plan to stay well, coordinating the aftercare treatment plan, arranging for and training the members of the transition team or ministry team when appropriate, and planning for and conducting a re-entry workshop once the individual has been discharged.
The re-entry consultation takes place after discharge. These meetings are planned with the social worker assigned to the patient to ensure that the transition back to the diocese or community is done in such a way that the ongoing recovery of the patient is a priority. The social worker will go to the respective community or diocese and hold meetings that are intended to inform and educate the support teams about the recovery process and provide opportunity for dialogues that will help sustain the transition. When a patient returns home they will need to share and process the treatment experience so that the aftercare team, the integration team and others can offer support and encouragement during this time of transition.
