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Dual Diagnosis Service

Discharge Planning

Discharge Planning at the Pre-Admission Stage
Even before a person has been admitted to the Dual Diagnosis Service, information has been requested from the referring agency as to their attempts to obtain housing for that individual.  If a placement has been arranged, we will continue to encourage that placement.  It is our belief that each patient deserves the opportunity to live in the community and not in a hospital setting.

Discharge Readiness
Discharge planning is the primary role of a Social Worker in the Dual Diagnosis Service.  This professional relies on the information provided by the unit's multidisciplinary team to develop an effective discharge plan.  

The process begins with a determination by the patient and the team that the person is ready for discharge.  The Social Worker informs the family of this plan, encourages their input, and keeps them informed regarding the process.  The family is an important part of the patient's life and that connection must be maintained after discharge. 

Placement Options
Potential placements are sought through ongoing liaison with community agencies (for example, Pressures and Priorities Committees, Access Centres, or Service Coordination) in the region of where the patient came from or has lived. 

If the patient's needs are mostly non-medical and he or she is under age 60, they will be referred to the Pressures and Priorities Committee in the identified area and will be put on a wait-list for group home housing and support services.  These committees are comprised of representatives from community agencies and they prioritize placements based on need.

Service Coordination is the agency that provides the same type of service to developmentally disabled persons in Ottawa.  If the patient is 60 or older, or if their medical needs are more substantial than the services provided in a group home setting, that person is referred to the Access Centre for long-term care placements in nursing homes.  There is often a long waiting list for all of these placements.

Discharge Process
The discharge process is unique for each patient depending on his or her needs.  When a placement is identified, the Social Worker facilitates ongoing meetings with the residence staff and community service providers to determine if the patient will receive sufficient support, will be a good >fit = in the environment, and that there are no other factors that will interfere with a placement.  

These meetings will continue during the discharge process in order to assist the patient with this transition.  The Social Worker organizes patient visits to the residence and arranges opportunities for that individual to meet with the service organizations that will be providing follow-up.  

Post-Discharge Support Services
It is important that the patient has ongoing support after discharge to help him or her adjust to living in the community.  In Leeds and Grenville Counties, referrals can be made to the Assertive Community Treatment Team for the Dually Diagnosed (ACTTDD) which provides ongoing support for the dually diagnosed population.  They provide therapeutic services 7 days a week and can be contacted after hours in an emergency.

In Ottawa, a dually diagnosed individual can be referred to the Canadian Mental Health Association, for example Service Brokerage, Assertive Community Treatment Teams (ACTT) and Geriatric Outreach Teams for ongoing support.  

Also, the Dual Diagnosis Consultation Outreach Team in Ottawa or Kingston can be accessed if further assessment, consultation, and education for that person and service providers are needed.

Depending on the patient's needs where they live, the Social Worker will arrange for the appropriate support agency to be involved with that person and placement agency early in the discharge process to ensure a smooth transition into the community.