At Faircape, we understand that the rehabilitation journey doesn’t end when you leave the hospital but adjusting at home can sometimes feel overwhelming.
Discharge planning is important in bridging the gap between the structured support of our facilities and safe, confident healing at home.
Why Discharge Planning Matters
In hospitals and sub-acute facilities, patients benefit from a highly structured environment. At Faircape, all patients are screened by our interdisciplinary team (IDT), who work together to provide every patient with professional medical care, emotional support, nutritious meals, assistance with medication and household tasks, and guidance every step of the way.
They also screen patients for discharge, working closely with our discharge planners to ensure a seamless transition and to determine whether a social worker’s involvement is needed.
Every case is assessed individually, as not all patients require post-discharge support. When they do, our compassionate discharge planners and social workers are equipped to understand the unique needs of each patient. Some patients manage well with family assistance for example, while others may face unexpected mobility limitations.
Behind the scenes, our teams are always collaborating to ensure the right professionals are involved in each decision.
Faircape’s four-step approach ensures that no patient is left to navigate these alone.
- Early Assessment from our IDT
Within 24 hours of admission, our interdisciplinary team of doctors, occupational therapists, nurses, physiotherapists, carers, social workers and a dietician reviews the patient’s baseline function, rehabilitation goals, and expected length of stay. Importantly, they also anticipate post-discharge care needs and work with the discharge planner to, where necessary, assign the appropriate social worker. - Dedicated Discharge Planner at Every Facility
Each of our rehabilitation centres has a discharge planner on- site who works with the IDT to screen each patient. . They will consider the patient’s physical abilities, emotional well-being, support systems, and potential risks, ensuring they receive the right level of support. - Extensive Social Work Support
For patients or families requiring additional assistance, we partner with Empowered To Thrive, an independent social work practice. Their services are covered by most medical aids, and includes counselling, guidance for caregiving, documentation support, and help adjusting to new care needs. - Family Communication and Support
Families are an integral part of recovery and our discharge planners and social workers ensure that loved ones understand what care will be required at home and provide the resources and guidance to implement it confidently.
The Outcomes We Strive For
Even the most motivated patients can struggle without preparation, which is why a thoughtful discharge plan is essential to maintaining rehabilitation progress.
- Patients leave with confidence, fully supported medically, emotionally, and practically.
- Families are informed, empowered, and connected.
- The risk of readmission, injury, or setbacks is reduced.
- Rehabilitation becomes a sustainable, and empowering journey, and not just a hospital stay.
At Faircape Health we walk that final mile with you, and our goal is simply to make sure every patient heals with confidence, support, and dignity.
This article is intended for general informational purposes and should not replace professional medical advice. Patients are encouraged to consult their healthcare providers for individual guidance.
