Comprehensive Discharge Planning Research Articles

Older Patients in the Emergency Department: What Are the Risks?

The emergency department (ED) can pose an increased risk for frail older adults. As the number of older adults in the general population grows, so will the number of older adults who seek care in the ED. This article examines the kinds of problems for which older adults visit the ED and the assessments that can be performed to help reduce risks. Geriatric-friendly waiting areas, comprehensive discharge planning, and alternatives to ED visits are explored.

To evaluate the effectiveness of a discharge‐planning programme for hip fracture patients

This study aimed to evaluate the effectiveness of a comprehensive discharge-planning service for hip fracture patients, including length of stay, functional status, self-care knowledge and quality of life (QOL). Hip fractures are the most devastating result of osteoporosis. Care of these patients from the moment they enter the hospital until discharge and postdischarge is a challenging task, requiring a coordinated approach by an interdisciplinary team. An experimental design was used. Methods. Fifty hip fracture patients were recruited from a medical centre in Taipei, Taiwan and randomly divided into two groups. The control group received routine discharge nursing care and the experimental group received comprehensive discharge planning. After patient admission, researchers assessed discharge-planning needs, provided discharge nursing instruction, coordinated services and determined discharge placement based on assessment results. (i) Mean age of 50 hip fracture patients was 78.75 (SD 6.99) years. Mean length of stay was 6.04 (SD 2.41) days for the experimental group and 6.29 (SD 2.17) for the control group. Difference between groups was not significant (t = -0.394, p = 0.696). (ii) The self-care knowledge of the experimental group was higher than that of the control group (F = 11.569, p = 0.001). (iii) Significant improvements were observed in functional status of both groups at three months postdischarge, with no significant differences observed between groups. However, the functional status of experimental group patients showed a slightly better trend than that of the control group. (iv) At three months postdischarge, QOL of experimental group patients was better than control group patients. A comprehensive discharge-planning service can improve hip fracture patients' self-care knowledge and QOL. Results of this study can be used clinically as a basis for practical implementation of discharge-planning services in fracture patients.

Risk for Suicide among Medicaid Beneficiaries

Demographic, diagnostic, and service expenditure characteristics of Florida Medicaid enrollees who died by suicide were investigated. Among persons receiving Medicaid and Supplemental Security Income (SSI), findings indicate the most powerful predictors of suicide were involuntary psychiatric examination, mental health hospitalization, and high mental health service use. Among Medicaid enrollees not receiving SSI, strongest suicide predictors were mental health hospitalization, high expenditures for physical health medications, and involuntary psychiatric examination. Findings suggest reducing involuntary psychiatric examinations and mental health hospitalizations while improving physical health may reduce suicide in the Medicaid population. Comprehensive hospital discharge planning, adherence monitoring with follow-up care, training mental health providers in assessing suicide lethality, and providing adequate assessment time are all crucial to achieve these objectives.

The effectiveness of telephone-based post-discharge nursing care in decreasing readmission rate in patients with heart failure: A systematic review

BACKGROUND: The importance of comprehensive discharge planning plus post discharge support intervention studies have been advocated for patients with heart failure. Telephone-based post-discharge nursing care was reported as a significant nursing care approach that is believed to promote continuity of care. However, there is a lack of systematically examined evidence to support the effectiveness of nurse-led telephone-based post-discharge care for the heart failure patients. OBJECTIVE: The purpose of this study was to examine the best available evidence to determine the effectiveness of telephone-based post-discharge nursing care of patient with HF and to quantify the effect on all-cause readmission rates of these patients. SEARCH STRATEGY: A thorough search of published and unpublished literature was conducted from 1990 to 2009. First, computer databases such as CINAHL, MEDLINE, COCHRANE EMBASE, and Dissertation Abstracts International were included and then, reference search was conducted with relevant studies. Initial keywords were "readmission," "heart failure," "*tele*", "nurs*, "post-discharge", telephone-based." SELECTION CRITERIA: Randomized controlled trial studies using the telephone-based post-discharge nursing care was selected. Outcome was defined as frequency of unplanned HF symptoms associated all-cause hospital readmission rate during the 6 months after discharge. DATA COLLECTION AND ANALYSIS: Included studies were critically evaluated for methodological quality by independent two reviewers. Data were extracted and then analyzed using the JBI-MASTARI and the RevMan 5 program. MAIN RESULTS: A total of 10 randomized controlled trial studies were included for this study. The study result showed that telephone-based post-discharge nursing care was a significant intervention especially decreasing hospital readmission rate among HF patients. CONCLUSION: The findings of this review suggest a positive effect of telephone-based post-discharge nursing care and that it is an effective intervention in decreasing readmission rate among HF patients. IMPLICATIONS FOR PRACTICE/ RESEARCH: The results of this systematic review indicate the need for well designed studies that examine other aspects of post-discharge nursing telephone interventions to decrease hospital readmission rate among HF patients including: cost-effectiveness, feasibility and appropriateness.

Postdischarge Environmental and Socioeconomic Factors and the Likelihood of Early Hospital Readmission Among Community-Dwelling Medicare Beneficiaries

This study attempts to determine the associations between postdischarge environmental (PDE) and socioeconomic (SES) factors and early readmission to hospitals. This study was a cohort study using the 2001 Medicare Current Beneficiary Survey and Medicare claims for the period from 2001 to 2002. The participants were community-dwelling Medicare beneficiaries admitted to hospitals, discharged home, and surviving at least 1 year after discharge (n = 1,351). The study measurements were early readmission (within 60 days), PDE factors, and SES factors. PDE factors consisted of having a usual source of care, requiring assistance to see the usual source of care, marital status, living alone, lacking self-management skills, having unmet functional need, having no helpers with activities of daily living, number of living children, and number of levels in the home. SES factors consisted of education, income, and Medicaid enrollment. Of the 1,351 beneficiaries, 202 (15.0%) experienced an early readmission. After adjustment for demographics, health, and functional status, the odds of early readmission were increased by living alone (odds ratio or OR = 1.50, 95% confidence interval or CI = 1.01-2.24), having unmet functional need (OR = 1.48, 95% CI = 1.04-2.10), lacking self-management skills (OR = 1.44, 95% CI = 1.03-2.02), and having limited education (OR = 1.42, 95% CI = 1.01-2.02). These findings suggest that PDE and SES factors are associated with early readmission. Considering these findings may enhance the targeting of pre-discharge and postdischarge interventions to avert early readmission. Such interventions may include home health services, patient activation, and comprehensive discharge planning.

Implementing the Comprehensive, Continuous, Integrated System of Care Model for Individuals with Co-Occurring Disorders: Preliminary Findings from a Residential Facility Serving Homeless Individuals

ABSTRACT This study assessed the effectiveness of an evidence-based treatment model for homeless individuals with co-occurring diagnosed mental health and substance use disorders. The model, Comprehensive, Continuous, Integrated System of Care (CCISC), has been recognized by the Substance Abuse and Mental Health Services Administration as one of the best treatment protocols in the United States (Minkoff & Cline, 2004). During residential treatment, clients received medical care, counseling, psychiatric/psychological evaluation, recreational and vocational services, as well as comprehensive discharge planning. All 76 participants were administered measures assessing housing and employment status, as well as mental health symptomatology and levels of substance use at both baseline and six-month follow-up. Analyses revealed significant improvement in all assessment categories at six-month follow-up as well as client satisfaction with the program. The Comorbidity Program Audit and Self-Survey for Behavioral Health Services (COMPASS), a standardized measure to assess fidelity to the CCISC model, was utilized annually and indicated that the CCISC principles of care were being implemented as intended. These results underscore the effectiveness of an evidence-based model for treating clients with co-occurring mental health and substance use disorders.

The Evolving Standard of Decency: Postrelease Planning?

In the 30 years since the U.S. Supreme Court’s decision in Estelle v. Gamble (1976), the evolving standard of decency on which the decision was based has been better articulated and defined by other courts, using Estelle as a basis. This article addresses the practical, ethical, and legal issues in understanding the recent emphasis on planning for an inmate’s release back to the community. Specific court cases and laws are discussed to highlight which inmate health and behavioral needs presently require comprehensive discharge planning and what can be expected in the future.

Psychosocial Profile of Elderly Patients Discharged from a Community Hospital

Social workers have historically been an advocate for vulnerable groups. One such vulnerable group is elderly patients who have been shown to have multiple, chronic health problems. The current fiscal environment favors shortened lengths of stay, potentially leaving these vulnerable patients at risk for adverse outcomes upon discharge, especially for those discharged home as opposed to institutional settings. The purpose of the study was to characterize the biopsychosocial risks for adverse outcomes in the elderly patients discharged home from Guelph General Hospital (Ontario, Canada). The objectives were to (1) estimate the number of elderly people who indicate biopsychosocial risk for adverse outcomes, (2) determine the specific risks and their severity, and (3) estimate the number of readmissions to hospital within three months after discharge. Standardized, self-reported scales were used to measure risks in elderly patients at discharge from acute care medical and surgical units. The sample included 62 patients with a mean age of 79 years. At discharge almost 40% of the patients were considered at risk for adverse outcomes, 11% indicated depression, 45% indicated psychological distress, 13% showed cognitive impairment, and 62.5% (35/56) had at least one nutritional concern. Over the three-month follow-up period, there were 23 readmissions, 8 ED visits (not mutually exclusive), and 7 outpatient visits. The mortality rate over the three-month period was 5% (3/62). Many elderly patients who were discharged from hospital to home experienced several challenges medically, psychologically and some also experienced social adversities. The implication is that these patients may benefit from a more comprehensive discharge plan than is currently practiced that addresses their challenges.

Exercise Training in Chronic Heart Failure

Life is movement. — —Aristotle (fourth century bce) Heart failure is a major clinical and public health problem in Western countries. It is estimated that nearly 23 million people have heart failure worldwide. In the United States, 550 000 new cases are reported each year, and the age at diagnosis shifted from 65±9 years in 1950 to 1969 to 80±10 in 1990 to 1999. Approximately 69% of men and 45% of women die within 5 years of the onset of symptoms.1 In the United States, half of inpatients >65 years of age with chronic heart failure (CHF) are readmitted within 6 months of hospital discharge, suggesting insufficient coordination of care among different operators and/or inefficient comprehensive discharge planning. Articles pp 3086 and 3095 Despite the progress of medical therapy, there is no evidence that the prognosis of heart failure in the community has changed over the last decades.1 It is conceivable that more individuals are surviving an initial acute cardiac event and that the first manifestation of heart failure is delayed. Thus, heart failure is a very demanding pathology requiring personalized disease management programs that raise the costs of medical care. With the aging of the population and the decline in mortality from other pathologies, it is likely that CHF will continue to increase. In the United States, the number of new cases of heart failure is expected to rise from 3 million in 1990 to 5.7 million in 2030. There is evidence that oxidative stress is elevated in CHF as a result of increased production of free radical species capable of attacking several organic molecules, including lipids, proteins, and nucleic acids not properly counterbalanced by antioxidant systems. Oxidative stress has many effects on myocardial structure and function. However, its role in heart failure is still unclear. For …

Hospital Discharge of Older Adults

When an older adult is discharged from the hospital, she or he should have an individualized, comprehensive discharge plan to help prevent unnecessary complications and rehospitalization. But the large number of older adults who are hospitalized and their typically greater needs can make creating such a plan a challenge for clinicians. Clear communication among hospital personnel, patients, family members, case managers, and community caregivers (such as home health care nurses and long-term care staff) is essential. In examining effective discharge planning for this population, this article examines five discharge models.

Clinical Nurse Specialist Practice Within the Acute Care for Elders Interdisciplinary Team Model

As the complexity of care increases for hospitalized older adults, the clinical nurse specialist is essential for ongoing development of nursing practice and care standards. This article describes the Acute Care of the Elderly (ACE) model for interdisciplinary management of older adults and clinical specialist responsibilities within this interdisciplinary team. Within the model, clinical care specialists utilize clinical expertise and consultation skills reflecting three spheres of practice related to care of high-risk community-dwelling older adults admitted an acute medical unit. The goal for this patient group is to achieve medical stability while preserving maximum functioning. The Acute Care of the Elderly team members include primary nurses (staff nurses), physicians, clinical care specialists, therapies, social workers, dietitians, pharmacists, and a discharge planner. Under the leadership of the primarily nurse, the team develops a comprehensive care and discharge plan, implemented across a care continuum. Using protocols and working together, the team delivers cost-effective, coordinated care that promotes process improvement resulting in practice that is in alignment with current standards of care.

Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care

Acute hospital general medicine services care for ageing complex patients, using the skills of a range of health-care providers. Evidence suggests that comprehensive early assessment and discharge planning may improve efficiency and outcomes of care in older medical patients. To enhance assessment, communication, care and discharge planning by restructuring consistent, patient-centred multidisciplinary teams in a general medicine service. Prospective controlled trial enrolling 1538 consecutive medical inpatients. Intervention units with additional allied health staff formed consistent multidisciplinary teams aligned with inpatient admitting units rather than wards; implemented improved communication processes for early information collection and sharing between disciplines; and specified shared explicit discharge goals. Control units continued traditional, referral-based multidisciplinary models with existing staffing levels. Access to allied health services was significantly enhanced. There was a trend to reduced index length of stay in the intervention units (7.3 days vs 7.8 days in control units, P = 0.18), with no change in 6-month readmissions. In-hospital mortality was reduced from 6.4 to 3.9% (P = 0.03); less patients experienced functional decline in hospital (P = 0.04) and patients' ratings of health status improved (P = 0.02). Additional staffing costs were balanced by potential bed-day savings. This model of enhanced multidisciplinary inpatient care has provided sustainable efficiency gains for the hospital and improved patient outcomes.

Benefits of Comprehensive Inpatient Education and Discharge Planning Combined With Outpatient Support in Elderly Patients With Congestive Heart Failure

Multidisciplinary disease management programs for congestive heart failure have been shown to substantially reduce readmission rates, resulting in a reduction of costs. These interventions, however, have typically included changes in medical management, making it difficult to quantitate the key elements of a successful program involving education, discharge planning, and transitional care in the outpatient setting. The investigators utilized an experienced cardiac nurse educator to coordinate a targeted inpatient congestive heart failure education program coupled with comprehensive discharge planning and immediate outpatient reinforcement through a coordinated nurse-driven home health care program. The comprehensive intervention resulted in a marked reduction in 6-month readmission rates, from 44.2% to 11.4% (p=0.01). The average total cost saving for each subject in the interventional group was $1541, based on the decreased utilization of both skilled nursing services and home health care during outpatient follow-up. The costs to implement an inpatient education program were negligible, at $158 per subject. There was no difference in discharge medications or medical management protocols that would have influenced these results.

Nutrition concerns in discharge planning for older adults: A need for multidisciplinary collaboration

This survey of 84 case managers (CMs) (88% response rate) in 11 south Florida hospitals, in one for-profit health care system, sought to identify their discharge planning concerns regarding the food and nutrition needs of older patients, how they addressed these concerns, and the degree to which registered dietitians (RDs) were involved. Most CMs were female (82 of 84, 98%), older than age 40 (59 of 84, 70%), and were registered nurses (51 of 84, 61%). Almost all (82 of 84, 98%) reported job barriers, including excessive patient loads and responsibilities and limited community services. Almost all said that nutrition-related diseases and factors (eg, chewing/swallowing problems, poor appetite, modified diets, poor dentition) strongly influenced discharge planning. Many perceived community nutrition resources (eg, congregate meals, food stamps, shopping assistance, outpatient dietitians) as not readily available. While physicians, nurses, social workers, and physical therapists were identified as very important in discharge planning, RDs were not; almost half of CMs consulted them infrequently, if at all. Strategies for the six nutrition-related case scenarios were inconsistent. Home-health agencies were chosen most often and outpatient RDs least often. Comprehensive discharge planning must include more attention to nutrition with greater input from clinical, outpatient, home health, and community RDs through, for example, attendance at hospital discharge planning rounds, inservices for CMs, and better marketing of RD services. More RDs can and should become CMs to help serve the number of older adults with nutrition-related chronic conditions.

Comprehensive discharge planning and post-discharge support reduces hospital readmission in older people with congestive heart failure

SummaryQuestionDoes comprehensive discharge planning and post-discharge support reduce readmission rates for older people with congestive heart failure?Study DesignSystematic review with meta-analysis.Main results18 RCTs (N=3304) met inclusion criteria. Comprehensive discharge planning and post-discharge support significantly reduced re-admission rates compared with usual care (35% vs. 43%; p<0.001: see Results table). There were no significant differences in mortality or length of hospital stay between groups (intervention vs. usual care—mortality 14% vs. 17%, p=0.06; length of hospital stay 8.4 days vs. 8.5 days, p=0.60). The intervention increased quality of life scores significantly more from baseline compared with usual care (25.7%; 95%CI 11.0 to 40.4% vs. 13.5%, 95%CI 5.1% to 22.0%). There was no significant increase in monthly medical costs per patient between groups (-$536, 95%CI $956 to -$115, for US trials).Authors’ conclusionsIn elderly people with congestive heart failure, comprehensive discharge planning with post-discharge support significantly reduced readmission rates. Routine application of such an intervention should be considered.

Review: comprehensive discharge planning plus post-discharge support reduces total readmissions in older patients with congestive heart failure

Phillips CO, Wright SM, Kern DE, et al . Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis. JAMA 2004;291:1358–67.[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Q In...

Comprehensive discharge planning with postdischarge support for older patients with congestive heart failure: a meta-analysis.

Comprehensive discharge planning plus postdischarge support may reduce readmission rates for older patients with congestive heart failure (CHF). To evaluate the effect of comprehensive discharge planning plus postdischarge support on the rate of readmission in patients with CHF, all-cause mortality, length of stay (LOS), quality of life (QOL), and medical costs. We searched MEDLINE (1966 to October 2003), the Cochrane Clinical Trials Register (all years), Social Science Citation Index (1992 to October 2003), and other databases for studies that described such an intervention and evaluated its effect in patients with CHF. Where possible we also contacted lead investigators and experts in the field. We selected English-language publications of randomized clinical trials that described interventions to modify hospital discharge for older patients with CHF (mean age > or =55 years), delineated clearly defined inpatient and outpatient components, compared efficacy with usual care, and reported readmission as the primary outcome. Two authors independently reviewed each report, assigned quality scores, and extracted data for primary and secondary outcomes in an unblinded standardized manner. Eighteen studies representing data from 8 countries randomized 3304 older inpatients with CHF to comprehensive discharge planning plus postdischarge support or usual care. During a pooled mean observation period of 8 months (range, 3-12 months), fewer intervention patients were readmitted compared with controls (555/1590 vs 741/1714, number needed to treat = 12; relative risk [RR], 0.75; 95% confidence interval [CI], 0.64-0.88). Analysis of studies reporting secondary outcomes found a trend toward lower all-cause mortality for patients assigned to an intervention compared with usual care (RR, 0.87; 95% CI, 0.73-1.03; n = 14 studies), similar initial LOS (mean [SE]: 8.4 [2.5] vs 8.5 [2.2] days, P =.60; n = 10), greater percentage improvement in QOL scores compared with baseline scores (25.7% [95% CI, 11.0%-40.4%] vs 13.5% [95% CI, 5.1%-22.0%]; n = 6, P =.01), and similar or lower charges for medical care per patient per month for the initial hospital stay, administering the intervention, outpatient care, and readmission (-359 dollars [95% CI, -763 dollars to 45 dollars]; n = 4, P =.10 for non-US trials and -536 dollars [95% CI, -956 dollars to -115 dollars]; n = 4, P =.03, for US trials). Comprehensive discharge planning plus postdischarge support for older patients with CHF significantly reduced readmission rates and may improve health outcomes such as survival and QOL without increasing costs.

Suicidal Behavior in a Young Offender Population

Young offenders have numerous problems, including increased psychopathology, housing, and psycho-social stresses and increased rates of substance abuse. The current study investigated the contribution that substance use might make to a particularly vulnerable group of young people. Of the 300 young people approached for the study, 23.7% reported a prior suicide attempt. For this group, the most significant predictors of a prior suicide attempt were negative affect, prior exposure to violence, and housing stress. Life-time substance-use variables were most predictive of the number of suicide attempts a young person might make. Self-reported lethality (the expectation that on the last attempt the young person expected to die) was not strongly predicted by any variable. The research identifies the important role that dynamic risk factors (such as mood, substance use, and psychosocial stressors) play in increasing the risk of self-harm for young offenders, and raises the need to provide for more comprehensive discharge planning and support in order to manage these needs.

Challenges and opportunities in quantifying the quality of care for acute myocardial infarction: summary from the Acute Myocardial Infarction Working Group of the American Heart Association/American College of Cardiology First Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.

Acute myocardial infarction (AMI) is a catastrophic manifestation of coronary artery disease that strikes more than 900 000 Americans each year. One fourth of afflicted patients die, and many survivors develop impaired functional status, anginal symptoms, and diminished quality of life. Fortunately, an explosion in scientific discovery and clinical research has created great potential for treating patients, and concurrent with these advances, there has been a marked decrease in AMI mortality.1 Yet the full benefit of scientific progress is often unrealized by patients because of the gap between knowledge and its application to clinical care. To address this gap, the AMI Working Group of the first American Heart Association (AHA)/American College of Cardiology (ACC) Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke brought together national leaders and committed practitioners to share knowledge and insights on measuring and improving the quality of AMI care (see Acknowledgments for Working Group members). This group sought to create a comprehensive framework for quantifying the components of AMI care and to summarize current methodological considerations in quality assessment/improvement while formulating a research agenda to address unmet needs in the field. The present report supplements the overall insights gained from the conference2 with data specifically relevant to the quantification of care for AMI patients. Although new evidence may alter the relevance of specific measures, it is hoped that the principles described in this report will assist local and national organizations in their efforts to improve the quality of care for patients with AMI. As a means of conceptualizing the components of quality assessment, the Working Group on AMI embraced the approach of Donabedian,3 which considers 3 domains of quality: structure, process, and outcome. Structure refers to those aspects of care that exist independently of the patient. Examples …

Influence of Drugs, Demographics and Medical History on Hospital Readmission of Elderly Patients

To investigate factors that influence hospital readmissions of elderly patients and to construct a robust hospital readmissions predictive model. Each hospitalised patient was interviewed and medical, demographic and socioeconomic data were obtained from their medical charts. These patients were followed up prospectively for 1 year post discharge with all unplanned readmissions to general medical (including cardiology) wards during this time period recorded. Univariate analysis (chi-squared) was used to identify variables that had at least a minimal association with one or more unplanned readmissions 12 months post discharge (p < 0.25). These were entered into backward stepwise elimination logistic regression analysis (model entry set at p = 0.05). Examination of the significance of the log-likelihood ratio test for each variable determined its contribution to the model. Data from a total of 487 elderly patients (≥65 years of age) with non-elective admissions to general medicine wards were used to refine the readmissions model. The refined model was then validated using similar data retrospectively collected from medical charts regarding 732 elderly patients (≥65 years of age). Multivariate logistic regression analysis yielded a nine-variable model, which contained both predictive and protective variables for one or more readmissions 12 months post discharge from hospital. This model had a specificity of 79.3%, sensitivity of 60.0% and overall accuracy of 71.2% (cut-off point of p = 0.5). When the model was applied to the validation population, an overall percentage accuracy in classification of 65.2% was obtained. This refined and validated hospital readmissions predictive model could be used by healthcare professionals to help identify vulnerable patients upon admission to hospital, and to put in place a comprehensive discharge planning process.