When patients are ready for discharge, they are competent in self-care, but require further guidance and support. It is believed that the outreach nurse is capable of preparing these patients for discharge and of controlling their self-care after discharge. Using an assessment tool, the outreach nurse determines the adequacy of a patient’s knowledge, skills, and willingness to meet his/her self care requisites after discharge as part of the follow-up. The outreach team initiates and maintains good relationships with community health organizations.

The supportive education role of the rehabilitation team is basically fulfilled through the outreach team. Members are representatives of the medical team: 1. Physician
2. Nurse
3. Social worker
4. Physiotherapist
5. Occupational Therapist.

The team holds weekly meetings to discuss each past week’s activities and to plan for the coming week.

Goals

1. Minimize the readmission rate through the early detection of complications.
2. Control/evaluate the patients self-care after discharge./
3. Involve the family in caring for the patient, to provide both the patient and family with support, and to keep the medical team well informed about any problems and complications.
4. Arrange for patient care in the community. This includes locating clinics/organizations as close as possible to the patient’s residence and providing the patient with adequate care plans.
5. Plan and hold seminars and workshops to educate community health workers on the concept of rehabilitation.

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