Connecting Your Patient With the Right Support

This series has championed the idea that most of what goes wrong after discharge is preventable, with tools that nurses already have: the discharge conversation started early, the scope map, the watch list, the layered team, the one-page handover.

Given this recent shift in focus, the only real question left is, when you have determined that a patient requires home support, what does "connecting" involve and how much of your time can that take?

The honest constraint

Any referral pathway intended for nurses will have to pass an "office hours" test and needs to be able to function in minutes, not meetings. The path below is designed accordingly. It is your clinical contribution that only you can do, the need for it, the writing of the handover; the searching, choosing and arranging is done by the patient and family, and the platform does the administrative lifting. The nurse who attempts to do everything on her own ends up spending time that she doesn't have and, more importantly, making decisions for the patient.

Design: pointing, picking, carrying.

The pathway, in four moves

Name the need out loud. The one best act of all is the one that most patients never hear: there is help available for just this, and it's easier to get than you think. But for families, home support is a bureaucratic epic, and if they hear otherwise from a nurse, then a vague worry turns into something they can act on.

Point to the door that matches the funding. The triage is completed in 30 seconds. There may be core supports that are available now to a person with a disability, or at the time they are accessing the NDIS, and their support coordinator (if they have one) may be their next point of contact. Older patients may have aged care supports in place, or may be best served by private arrangements whilst systems are slow. If families are paying for private funding, they can take action right away. You're not the final expert on the funding, you're the one who tells which door is the right one to go through.

Hand over the handover. The one page referral handover from earlier in this series is your clinical contribution, made portable: person, practical picture, the safety essentials, a watch list, an escalation line. Ten minutes, once, and each worker the family employs begins informed.

Let the family search with the patient. On Support Network the family search for availability, experience and language, read profiles, shortlist with the patient, and agreements and invoicing occur through the platform's infrastructure, while verification and screening occur at the platform level and meet and greets occur before commitments are made. The search can start from the day the need is identified, as with discharges, support can be available at the front door prior to the patient's arrival.

What this looks like from the ward

The entire nursing footprint of a well done referral is less than 20 minutes spread where it matters: 2 minutes spent naming the need on day one, 1 minute of funding triage, 10 minutes for writing the handover and a few minutes to ensure the family is aware of the search and the handover travels with who they want. All other information (profiles, choices, agreements, rates within limits) is between the family, the worker and the platform, where it belongs.

How this plays out in practice

Think about the opening line of this series: "Who will wash my mother on Tuesday?" The nurse responds with the pathway, names the option, states that this family will fund privately for a 6 week recovery, writes the handover on that afternoon and demonstrates the search to the daughter on her own phone. That evening, the daughter narrows down the two workers and the meet and greet is conducted via video on the next day, and the selected worker reads the handover from the car outside on the first Tuesday morning.

Nursing time: nineteen minutes. Overall difference: the whole recovery.

Next steps

Run the four moves with one patient this week that you're concerned about at home. Name it, point and hand it over to them and let them look for it. Afterwards see what it cost you, and what it did not. The same story applies to your hours on the platform, as a nurse.

Also for nurses: your own hours on the platform

One last thing to note: this series has been talking to you as a referrer, and the platform has another door for the profession. Nurses can take their own hours on Support Network, whether that's a few flex visits in the community alongside their regular work, or a complete nursing practice with clients choosing you, rates you set (as per applicable limits), and agreements and invoicing that are provided by Support Network.