# data[].attributes.body
Active listing, being empathetic, discuss her goals, make a plan, keep in contact with her

# data[].attributes.body
Ground yourself and remember it's not the end of the world

# data[].attributes.headline
to overcome barriers you have to be determined

# data[].attributes.subject
to overcome barriers you have to be determined

# data[].attributes.body
Communication with the General Practitioner (GP) regarding the Occupational Therapy (OT) referral.

# data[].attributes.body
Ensure patient is adequately and consistently educated in matters concerning self-care at home.

# data[].attributes.body
If the patient is not checked on later on there is no way of knowing if the care plan is effective or not

# data[].attributes.headline
Lack of staff in the community, will effect home care package

# data[].attributes.subject
Lack of staff in the community, will effect home care package

# data[].attributes.headline
lack of coordination before case conference

# data[].attributes.subject
lack of coordination before case conference

# data[].attributes.headline
Patient not willing to go home due to loneliness 

# data[].attributes.subject
Patient not willing to go home due to loneliness 

# data[].attributes.headline
Lack of communication between patient and others on healthcare team on their wants and needs

# data[].attributes.subject
Lack of communication between patient and others on healthcare team on their wants and needs

# data[].attributes.headline
Begin from mission working with patient and mdt 

# data[].attributes.subject
Begin from mission working with patient and mdt 

# data[].attributes.body
Not being able to understand instructions

# data[].attributes.body
nurse and healthcare team being stressed and not taking enough time

# data[].attributes.body
Multidisciplinary team not agreeing with an appropriate care plan.

# data[].attributes.body
home care package

# data[].attributes.body
Language barrier

# data[].attributes.headline
patient might be unprepared to take care of themselves eg. with new chronic condition 

# data[].attributes.subject
patient might be unprepared to take care of themselves eg. with new chronic condition 

# data[].attributes.body
Busy occupational therapists

# data[].attributes.headline
Patient may not have been educated on medication and outpatient referrals 

# data[].attributes.subject
Patient may not have been educated on medication and outpatient referrals 

# data[].attributes.body
patients not being educated to care for themselves at home post discharge e.g changing a stoma bag at home

# data[].attributes.headline
Lack of communication between transfer of patient home and continuation of care.

# data[].attributes.subject
Lack of communication between transfer of patient home and continuation of care.

# data[].attributes.body
Have an MDT meeting to set up communication between OT, physio, PHN etc.

# data[].attributes.body
Lack of patient education

# data[].attributes.headline
Patient may not be educated on self management of chronic illness and may not be confident on how to deal with health crises 

# data[].attributes.subject
Patient may not be educated on self management of chronic illness and may not be confident on how to deal with health crises 

# data[].attributes.headline
no safe place for patient to go if unable to live alone and no relatives available

# data[].attributes.subject
no safe place for patient to go if unable to live alone and no relatives available

# data[].attributes.body
Home not suitable

# data[].attributes.headline
Family may be unsatisfied with home care package 

# data[].attributes.subject
Family may be unsatisfied with home care package 

# data[].attributes.body
Family could help with their daily activities or decision making

# data[].attributes.headline
Patient not satisfied with the care provided and may refuse to go home 

# data[].attributes.subject
Patient not satisfied with the care provided and may refuse to go home 

# data[].attributes.body
Lack of support

# data[].attributes.body
Home environment considering adjustments if needed to the house

# data[].attributes.headline
No space for a patient going back into the community-MSW trying to find acommadation for the patient 

# data[].attributes.subject
No space for a patient going back into the community-MSW trying to find acommadation for the patient 

# data[].attributes.headline
Bad planning between multi-discplinary team

# data[].attributes.subject
Bad planning between multi-discplinary team

# data[].attributes.headline
Multiple professions doing same tasks/ Poor delegation 

# data[].attributes.subject
Multiple professions doing same tasks/ Poor delegation 

# data[].attributes.body
lack of communication

# data[].attributes.headline
No availiablity of nursing home/day care centre

# data[].attributes.subject
No availiablity of nursing home/day care centre

# data[].attributes.body
Home not accessible

# data[].attributes.body
no availability in place of desired place of discharge

# data[].attributes.body
Poor communication

# data[].attributes.body
home care package

ot referall

# data[].attributes.body
wards can often get busy

How can this be fixed you may ask?

plan ahead and stay organised to prevent this from happening

# data[].attributes.headline
Difficult staff/ Staff not on your level

# data[].attributes.subject
Difficult staff/ Staff not on your level

# data[].attributes.body
Lack of support

# data[].attributes.body
no place for the patient to go to be discharged , no place in nursing home etc

# data[].attributes.body
Time pressures

# data[].attributes.body
lack of communication

# data[].attributes.body
Deterioration in patient health

# data[].attributes.headline
no next kins to take care of the patient 

# data[].attributes.subject
no next kins to take care of the patient 