Transition Services & Social Work

Our philosophy: “Together, let’s get you home.”

Home is the best place for you to recover. From the moment you are admitted to hospital, it is important that we plan for your discharge together.

Transition Services

The Acute Transition Coordinator is a specialized Registered Nurse who:

  • Works to return or keep patients in their current home setting and ensures supports are in place to optimize patients’ independence and strengths
  • Promotes Destination Home by working with the patient, family and care team to keep patients healthy in their home for as long as possible. This can include providing encouragement, services and support to get patients home after a hospital stay
  • Coordinates care planning for patients admitted from continuing care to support a successful return
  • Manages referrals to community programs such as Home Care, post-acute and rehabilitative care, and continuing care when all other options have been exhausted

To learn more about Destination Home and Continuing Care Services, call the Alberta Health Services Community Care Access Information Line at 780.496.1300. Open 24 hours a day.

Social Work

Social Workers are members of the care team who:

  • Provide financial assessment and interventions to help patients and families financially plan for the patient’s transition back to community
  • Offer family and caregiver support
  • Mediate and assist with conflict resolution and advocacy
  • Ensure the patient’s goals and values concerning their care needs are communicated—either directly from the patient through their documented wishes or through an alternate decision maker
  • Help with the decision-making capacity process, alternate decision makers and related legal documents
  • Connect patients with appropriate community supports and resources

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