In this unit you have been following the journey of Joseph Russo from
the acute- care hospital setting to his return to the community.
This assessment requires you to examine how care will be transferred
from the hospital to his home. Joseph is being discharged home to the
same suburb/town/city in which you live (or have undertaken your
most recent PEP), and therefore you will need to seek information on
services available to meet his (and his family’s) complex needs in your
local community. You will need to consider the transfer of information
between differing services during his care transition. Mr. Russo does
not wish for his admission diagnosis to be disclosed or discussed.