Collaboration with Patient and Support Networks
Smooth transition requires this communication
Open communication
(RNAO BPG 1.0)
This professional advocates for the patient
Primary nurse
(RNAO BPG 4.0)
This professional is consulted with regards to medications
Pharmacist
Greater tolerance of activity indicates this
Ceftriaxone is working
This tool gives a summary of care and health teaching
PODS
Daughter can help in these ways
Check up on patient and administer the IV ceftriaxone
This risk factor prevents Marty from seeking medical help
His inability to drive
This professional gives final say to readiness (orders when the patient can go home)
Attending physician
This support ensures the patient is receiving the medications
Pharmacy medication fax
This is a resource for Marty to learn more
Patient health teaching through system navigation supports (Niagara Health, 2025)
This will ensure that the antibiotics are given full course (support persons)
Health teaching to the daughter
The patient requires this to know how to care for the PICC line
Patient teaching
This professional ensures the patient has proper supports at home
Social Worker
These two tools will ensure Marty has the right information regarding his medications
Best Possible Medication History and Medication Reconciliation
(RNAO BPG 4.0)
This teaching method lets Marty internalize his care plan
Teach Back Method (Marks et al.)
A consult with this professional will help facilitate homecare transition
Social Work
This limits the risk his comorbidities will interfere with the healing process
Patient teaching on diabetes management
This professional will assess and advocate for Marty
Primary Nurse
Rapid pain and swelling indicate this
Infiltration
These can be given to the patient to help his understanding of the health teaching
Additional resources (patient portal to his health information)
This program oversees public homecare in Ontario
Ontario Health atHome
These can interfere with his healing process (overarching term)
Social Determinants of Health (examples)
This professional assesses and coordinates the transition to homecare
Discharge Planner
Swelling of the arm greater than 2 cm, chest pain, arm, neck and face pain on right side of body indicate this
Thrombosis (local) or embolism (other symptoms)
(Hamilton Health Sciences, 2022)
Marty will need to access these appointments
Public Health Ontario for monitoring status of vegetation and lab blood work for monitoring ceftriaxone-induced complications