Reimbursement for Medi care hospital admission is determined by a pa tient's diagnosis related group classification, re gardless of length of stay. With the ever-increasing commitment to cos containment measures, patients an being discharged from the hospital ear Her, and they are possibly less ready for discharge. The elderly have com plex discharge planning needs and an particularly affected by early discharge. This puts increasing pressun on the health-care team, especially nurses, to determine patient readiness for discharge and to use this in formation in planning discharge care The purpose of this research was to study perceptions of readiness for discharge and the need for at-home, fam ily, and community resources among persons aged 65 years and older.
The following questions were addressed:
* What is the elderly patient's perception of discharge readiness prior tc discharge?
* What is the elderly patient's perception of discharge readiness after returning home?
* What family and community resources are used by the elderly patient after returning home?
* Do predischarge perceptions of levels of knowledge, pain, strength/ energy, mood, and functional ability differ from postdischarge perceptions?
Readiness for Discharge
Simmons found that patients who are involved in the discharge planning process and are able to choose their own course of action for posthospital care have lower mortality rates.1 Several factors can inhibit the patient's involvement in discharge planning, including diminished mental competency, reduced length of hospital stay, and lack or presence of family conflicts.
Fenwick discovered that patients, staff, and families have their own timetables (perceptions of when the patient is ready) regarding the patient's discharge.2 The planning process necessitates a balance between the client's physical, psychological, and social needs and the resources that the community can provide after discharge.
Arenth and Mamon found discrepancies between the nurse's assessment of client abilities and needs on discharge and the client's perception of needs.3 The nurse frequently overassessed the client's ability in activities of daily living. Also, nurses in this study frequently underassessed the need for special equipment in the home.
Using a telephone call-back system, Nicklin investigated problems encountered at home by cardiac surgery patients after discharge.4 She concluded that 40% of the concerns (cardiopulmonary, medication, and gastrointestinal) found in the first week at home could have been addressed in a predischarge class. She also noted that 43.6% of the concerns were serious enough to send clients to the emergency room. Leyder and Pieper found that most clients undergoing herniorrhaphy and cholecystectomy were able to rank concerns prior to discharge, and the concerns remained similar 1 week later. The areas of highest concern were related to physical activity after surgery.5
Kolditz and Naughton identified several factors that had to be present for the patient to perceive himself as ready to be discharged from the hospital.6 These factors include patient perception that his strength and energy are increasing, his emotions are returning to normal, he is independent in his activities of daily living, his wound is healing, his pain is decreasing, and his doctor assures him it is safe to leave the hospital.
Anderson found that in a surgical population under the age of 66 years, there was a marked discrepancy (54%) between the timing of the patients' attainment of readiness for discharge and professionals' judgment of the patient's readiness.7 Fifty-four percent of the patients (44% ready earlier; 10% not ready) attained readiness at a different time than the discharge date. Anderson found that levels of pain, strength/ energy, mood states, and functional ability significantly differed between patient's ready and nonready states during his hospital stay.
Smith, using Anderson's instrument, examined readiness perceptions and levels of pain, strength/energy, mood states, functional ability, and knowledge between predischarge and postdischarge times in an Australian population.8 Seventy-four percent of the under-65 patients were found to be ready at discharge. No significant differences were found in the levels of internal readiness factors before ( 1 to 3 days prior to discharge) and after discharge (12 to 14 days postdischarge). Smith added family and community resources to Anderson's tool and found that many patients needed assistance at home with shopping, transportation, meal preparation, and housekeeping.
The literature suggested patient perception of readiness as a major factor to be considered during discharge planning. The absence of data on an elderly population further suggested the need to target patients age 65 and over who have complex health-care needs for further study.
Forty-five cardiac or abdominal surgical patients age 65 years and older were invited to participate in the study. These subjects had to be able to read and write the English language, have recall of recent events, be alert and oriented, and be planning to be discharged to their own home. Thirty-five subjects completed the predischarge questionnaire. Ten additional subjects were approached to be in the study but declined for various reasons. Six subjects did not complete the second questionnaire (two of the subjects were no longer living at the address listed and the other four were readmitted to the hospital and chose not to complete the second questionnaire). Two subjects did not meet the surgical criteria and two others were not included because their second questionnaire was incorrectly scaled on the functional ability items.
The actual sample was reduced to 25 subjects. The age of the 25 respondents ranged from 65 to 86 years. Because all but one subject (24 people) fell into the age range of 65 to 80, no further subdivision by age group (65 to 80 as young-old and 80 years and over as old-old) was deemed necessary. The mean age was calculated to be 70.6 years of age with a standard deviation of 5 years. The sample was almost evenly divided between men (n= 11) and women (n= 14). The entire sample (N = 25) was Caucasian.
The marital status of the sample included 19 married subjects and 6 subjects who were separated, widowed, or divorced. The majority (76%) of subjects lived with their spouses. The rest of the sample had living arrangements that included living alone, living with their spouse and children, living with a friend, and living with children.
This sample included 11 (45.8%) high school graduates, 10 (41 .6%) subjects with 2 or more years of college, 2 (8.3%) subjects with less than a high school education, 1 (2.15%) subject with a teaching certificate, and 1 (2.15%) subject who did not answer the question. Eight members of the sample were housewives, 5 worked in business (ie, the phone company, business manager, clerk, and purchasing agent), 3 were engineers, 3 owned small businesses, 2 were teachers, 2 were professionals (ie, social worker and psychiatric nurse), 1 was a farmer, and 1 was a city treasurer.
The sample was almost evenly divided between thoracic (52%) and abdominal (48%) surgical procedures. Coronary artery bypass graft was the most common thoracic surgical procedure performed (p=10, 40% of the sample). Other thoracic procedures included a combined coronary artery bypass graft and a mediastinal exploration, a double valve replacement, and a pericardial window.
Of those subjects who had abdominal procedures, 5 subjects (20%) had some type of bowel procedure, and 7 (28%) had more than one procedure. All of the subjects indicated that they had been previously hospitalized. The length of their current stay ranged from 6 to 31 days. The average length of stay was 12.7 days with a standard deviation of 6.4 days. The average time between completion of the first questionnaire and the second questionnaire was 12.4 days with a standard deviation of 3.4 days and a range of 9 to 26 days. Because of the unpredictability of the patients' discharge date, 19 (76%) of the patients were interviewed on the day of discharge, 5 (20%) were interviewed 1 day prior to discharge, and 1 patient was interviewed 4 days prior to actual discharge.
The questionnaire developed by Anderson and Smith served as me data collection instrument and included two readiness questions, five factors of internal readiness measures, family and community resource questions, and demographic information. The five factors that measure internal readiness for discharge as developed by Anderson include pain, strength/energy, mood, functional ability, and knowledge.
Readiness for discharge was measured by Anderson's dichotomous (yes/ no) readiness question and an interval level question on readiness. Pain level was measured on three scales: physical sensations of pain, distress caused by the pain sensations, and pain with activity. An item from Wolfer and Davis's Recovery Inventory was used to assess the patient's strength and energy.9 Functional ability was measured based on Jette' s components of selfcare, moving out of bed and then from room to room, and other activities at home.10,11 A mood adjective check list was used to measure mood states. The knowledge item measure was taken from a study by Pender. 12
The questionnaire also included information on other descriptive factors (demographic data). Family and community resources (ie, primary provider of at-home care and what outside resources are used at home) were added by Smith.
The predischarge self-administered questionnaire (distributed 1 to 3 days prior to discharge) was given to subjects who had consented to participate. The second questionnaire was given to the subjects at discharge with instructions to complete it 10 to 12 days after discharge. On the ninth day after discharge, a phone call was made to remind the subject to fill out the questionnaire and mail it back in the selfaddressed stamped envelope.
RESULTS AND DISCUSSION
Perception of Discharge Readiness
The majority of the subjects (96%) anticipating discharge thought they were ready, whereas one subject thought she was not. In answer to the question, "Are you ready to be at home now?" the majority (96%) said they were, and one subject said she was still not ready to be at home.
The mean score on the readiness scale prior to discharge for the 25 subjects was 10, with a standard deviation of 2.3 and a range of 4 to 12. The mean score on the readiness scale postdischarge for n = 24 (one subject did not answer the question) was 1 1 , with a standard deviation of 2. 1 and a range of 3 to 12.
Changes in the Five Internal factors
The Wilcoxon Matched Pair Rank Sum Test was used to compare predischarge and postdischarge index scores on die five internal factors of readiness (pain, strength, functional ability, knowledge, and mood).
A significant difference at the .05 level was found between the predischarge and postdischarge index of functional ability (n = 23 and rank sum = .0486). Patients perceived themselves as more able to do activities at home after discharge than before discharge. No significant differences at the .05 level were found for me other four internal factors. However, at the .10 level, a trend was found between the predischarge and postdischarge levels of pain (n = 23 and rank sum - .0885). Patients perceived a decrease in pain from the first questionnaire to the second questionnaire.
Family and Community Services Used After Discharge
In answer to the question of what assistance would be needed at home, the following items were addressed: bathing, dressing, shopping, meal preparation, taking medications, wound care, dressing care, exercise, transportation, and housekeeping. Five activities were identified as problem areas by at least 50% of the sample before discharge. These activities included transportation (n = 24, 96%), housekeeping (n = 23, 95.8%), shopping (n = 22, 88%), meal preparation (n = 21, 84%), and wound care (n=12, 50%). Seven activities were again identified as needs by at least 50% of the sample after discharge. The same five activities listed preoperatively were mentioned postoperatively with the addition of bathing (n=13, 56.5%) and taking medication (n = 12, 52.2%). The majority of the sample identified non-nursing functions such as shopping, meal preparation, transportation, and housekeeping as activities with which they needed help at home. Family members were the primary providers of help at home.
Patients were also asked what referral services they would be using at home. Predischarge and postdischarge answers did not differ on this question. Seven (28%) subjects were receiving help from a visiting nurse, 5 (20%) were receiving housekeeping help, 3 (12%) were receiving help from home health aides, 2 (8%) were receiving help with meals, and 1 (4%) was receiving help from a social worker. A physician's order was the most common source of referral. The one exception was a subject whose daughter ran a home healtfi agency and arranged for her mother's care.
This study supports the results of Smith's investigation. Postdischarge needs for assistance with bathing, medications, housekeeping, shopping, meal preparation, and transportation were documented and noted to be predominantly non-nursing activities.
This finding is consistent with other research in gerontology. Wachtel, Fulton, and Goldfarb, in an evaluation study of 367 elderly patients, investigated predictors of institutional placement at discharge and found that the ability to perform instrumental activities of daily living is essential to continued life at home following hospitalization.13 Kane supports the notion of the ability to perform daily living activities is the key to independence, further noting that the largest segment of home care is service and unskilled care.14 Effective individualized discharge planning, including housekeeping services, could become a nursing product. Current housekeeping agencies do not have the background to provide nursing care, and it is unlikely that they will acquire this expertise.
Further studies need to be done with the 65 and older population because they have more complex discharge needs, including assistive technology. Haber noted that the application of technology has great potential for enhancing independent living through mobility, communication, and sensory devices.15 The sample in this research was small and possibly atypical. Almost all of the subjects were still married (not widowed), and the sample was evenly divided between men and women. However, additional studies with patients 70 and older could garner information on people who have less family support at home and may be at greater risk when discharged.
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