Planning the Homecoming

During your child's hospital stay, the hospital staff helped with many of the decisions and arrangements. At home, you will take on more responsibility for your child's care. There is a hospital staff person who is responsible for planning your child's discharge and return home. While it is your child's physician who sets the discharge date, the staff person will arrange and coordinate your child's discharge plans and follow-up care. The title of this staff person may differ from hospital to hospital. Descriptions of the different positions follow.

Social Worker

A social worker has special training in providing emotional support to families. Social workers are experienced in finding resources in the community and making referrals for continuing care.

Case Manager

This professional may work for either the hospital or an insurance company. Sometimes the position is called a care manager. It is the care manager's job to coordinate your child's care while still keeping track of your insurance benefits and the costs of care. The care manager can explain your choices for ongoing care. Most insurance companies or health maintenance organizations use care managers when the child has a very serious injury.

Discharge Planner or Continuing Care Coordinator

These titles are used in some hospitals for the person (usually a nurse or social worker) who coordinates the discharge plan and makes referrals for continuing care.

Discharge planning for your child may have started long before you were ready to start thinking about it. Ask to meet with the person or team developing your child's discharge plan. It is important to talk about your family's concerns and the needs your child will have when he returns home. Depending on your child's needs, it may be useful for the discharge planner to make a visit to your home. When the discharge plan has been written, ask for a copy.

The discharge plan can:

  1. identify home care needs
  2. provide information to your child's local doctor
  3. set up out-patient appointments for therapies
  4. arrange consultations with specialists
  5. send information to your child's school
  6. make referrals to agencies in your community
  7. give you information about programs for children with special needs
  8. refer you to the Brain Injury Association of New Hampshire
  9. refer you to parent support groups or parent-to-parent programs

Resource Facilitator

This professional works for the Brain Injury Association of New Hampshire. It is the resource facilitator's job to share knowledge through a team approach and to help families and survivors find and obtain resources in their communities.