Journal of Gerontological Nursing

Characteristics of Effective Discharge Planning Programs for the Frail Elderly

K Sue Haddock, RN, PhD

Abstract

Changes in the health-care reimbursement system have focused on cost containment without reduction in quality. In other words, hospitals are expected to provide services with fewer resources while still delivering effective patient care. This cost containment era directly challenges hospitals to discharge patients as soon as medically possible to minimize costs and maximize profits.1 Because of these expedited discharges, frail elderly patients have been identified as a group at risk for postdischarge difficulties and having the potential for costly réadmissions. Frail elders frequently have more complex needs but fewer material resources and social support systems, identification of at-risk groups and cost containment issues has renewed interest in discharge planning.2

Effective discharge planning is believed to be associated with an increase in the health status and satisfaction of elderly patients. Patients are provided with the services and support systems that enhance their abilities to continue self-care and health maintenance. Satisfaction is important because it creates an emotional tone that can augment patient teaching, increase acceptance of care, and positively influence future relations with the health-care system. Additionally, discharge planning has the potential to affect the accreditation, reputation, and profitability of a health agency.

Nurses involved in discharge planning require programs that address patient needs in a timely and effective manner so that the nurse is able to coordinate patient teaching, family and social support systems, and discharge dates. A formalized discharge planning program can be an important guide in the process. Therefore, the specific purpose of this study was to examine discharge planning programs for characteristics associated with positive patient outcomes. The broader purpose was to identify components of programs that would ultimately assist the nurse with efficient and cost-effective discharge planning.

CONCEPTUAL FRAMEWORK

Continuity of care (discharge planning) is defined as a coordinated process of activities that involves the client and health providers, who work together to facilitate the transition of health care from one institution, agency, or individual to another. The McKeehan and Coulton model provides a means of viewing the whole of discharge planning by seeing the relationship of its parts.3 Figure 1 depicts the three major components in the model: structure, related to program design; process, depicting various implementation activities; and outcome, focusing on program recipients.

In this model, the structure is classified as informal or formal. An informal design is composed of a philosophy that planning for continuity of care is inherent within all health-care professionals. No program elements are specified. A formal design refers to specific organizational elements used in the program design. Components in a formal design include written program policies, role descriptions, screening and assessment protocols, documentation requirements, methods for follow-up, and program evaluation. Because of recent changes in Joint Commission on Accreditation of Health Organizations and Health Care Financing Administration standards mandating discharge planning, only formal programs were considered in this study.

There are different approaches for implementation of discharge planning. The activities are placed on a continuum ranging from direct service to consultation. Direct service involves specific individuals (usually called discharge planners) who work directly with clients and families to facilitate discharge planning. Consultation programs subscribe to the belief that the bedside nurse is responsible for discharge planning. Some discharge planning programs are a combination, with the designated discharge planner identifying high risk clients and the bedside nurses implementing the discharge plan. However, designated nurses or social workers who are educated and experienced in the use of community resources should be available to the bedside nurse as consultants.

The outcome component focuses on program results and provides a basis for measurement. Measures of resource provision and patient satisfaction are two of…

Changes in the health-care reimbursement system have focused on cost containment without reduction in quality. In other words, hospitals are expected to provide services with fewer resources while still delivering effective patient care. This cost containment era directly challenges hospitals to discharge patients as soon as medically possible to minimize costs and maximize profits.1 Because of these expedited discharges, frail elderly patients have been identified as a group at risk for postdischarge difficulties and having the potential for costly réadmissions. Frail elders frequently have more complex needs but fewer material resources and social support systems, identification of at-risk groups and cost containment issues has renewed interest in discharge planning.2

Effective discharge planning is believed to be associated with an increase in the health status and satisfaction of elderly patients. Patients are provided with the services and support systems that enhance their abilities to continue self-care and health maintenance. Satisfaction is important because it creates an emotional tone that can augment patient teaching, increase acceptance of care, and positively influence future relations with the health-care system. Additionally, discharge planning has the potential to affect the accreditation, reputation, and profitability of a health agency.

Nurses involved in discharge planning require programs that address patient needs in a timely and effective manner so that the nurse is able to coordinate patient teaching, family and social support systems, and discharge dates. A formalized discharge planning program can be an important guide in the process. Therefore, the specific purpose of this study was to examine discharge planning programs for characteristics associated with positive patient outcomes. The broader purpose was to identify components of programs that would ultimately assist the nurse with efficient and cost-effective discharge planning.

CONCEPTUAL FRAMEWORK

Continuity of care (discharge planning) is defined as a coordinated process of activities that involves the client and health providers, who work together to facilitate the transition of health care from one institution, agency, or individual to another. The McKeehan and Coulton model provides a means of viewing the whole of discharge planning by seeing the relationship of its parts.3 Figure 1 depicts the three major components in the model: structure, related to program design; process, depicting various implementation activities; and outcome, focusing on program recipients.

In this model, the structure is classified as informal or formal. An informal design is composed of a philosophy that planning for continuity of care is inherent within all health-care professionals. No program elements are specified. A formal design refers to specific organizational elements used in the program design. Components in a formal design include written program policies, role descriptions, screening and assessment protocols, documentation requirements, methods for follow-up, and program evaluation. Because of recent changes in Joint Commission on Accreditation of Health Organizations and Health Care Financing Administration standards mandating discharge planning, only formal programs were considered in this study.

There are different approaches for implementation of discharge planning. The activities are placed on a continuum ranging from direct service to consultation. Direct service involves specific individuals (usually called discharge planners) who work directly with clients and families to facilitate discharge planning. Consultation programs subscribe to the belief that the bedside nurse is responsible for discharge planning. Some discharge planning programs are a combination, with the designated discharge planner identifying high risk clients and the bedside nurses implementing the discharge plan. However, designated nurses or social workers who are educated and experienced in the use of community resources should be available to the bedside nurse as consultants.

The outcome component focuses on program results and provides a basis for measurement. Measures of resource provision and patient satisfaction are two of the goals that can be assessed with individual clients or with aggregate groups such as the elderly. Using the McKeehan and Coulton model, programs can be systematically examined and evaluated for program effectiveness.

REVIEW OF LITERATURE

Discharge planning research has received considerable impetus since the implementation of Medicare's Prospective Payment System. A number of studies have focused on hospital- related outcomes of discharge planning. TTiese studies have attempted to determine the relationship of certain hospital and patient variables on length of stay4"6 and readmission rates.7 Other studies have concentrated on patient outcomes using placement status, functional levels, effectiveness of the communication process, provision of services, and participation in decision making as important variables to the adequate provision of services.8"10 The issue of patient satisfaction has not been researched in respect to discharge planning. However, patient satisfaction as an appropriate variable is upheld in health status literature.11

The results from previous research have been conflicting and inconclusive. Most studies have been conducted in teaching hospitals, medical centers, or hospitals in large metropolitan areas. Additionally, research on the relationships of program structure with patient outcomes has not been reported. This research studied the structure of discharge planning programs and patient outcomes in rural community hospitals.

RESEARCH QUESTION

In this study, the investigator examined discharge planning programs to determine which structure components and process of hospital discharge planning programs are associated with appropriate provision of postdischarge services and increased patient satisfaction. Appropriate provision of postdischarge services was defined as a proportion measure of services determined by comparing the patient's assessed need for postdischarge services with those services actually provided after discharge. Patient satisfaction was the degree to which a patient reported acceptability of the discharge planning for after-hospital services.

Table

FIGURE 1DISCHARGE PLANNING MODEL

FIGURE 1

DISCHARGE PLANNING MODEL

SETTING AND SAMPLE

The setting for this study was rural central Texas hospitals in communities of fewer than 50,000 residents. Eight hospitals meeting the criteria listed in Figure 2 consented to participate in this study.

The sample consisted of 10 eligible patients from each of the eight hospitals. A convenience sample was used and patients were selected sequentially. Figure 3 presents eligibility criteria.

PROCEDURE

Potential subjects were identified on admission to the hospital using the patient eligibility criteria. After informed consent was obtained, the investigator asked the patient to answer questions included on the Functioning Status Form. The Functioning Status Form was part of the Long Term Care Information System (LTCIS) developed by Falcone.12 The functioning status information was gathered through patient interviews taking 15 to 20 minutes per subject to complete. The patient's level of dependency to bathe, dress, toilet, transfer, eat/feed, and to perform bowel and bladder functions was assessed using observation, patient report, and chart review. These data were then used to complete the Translation to Service Needs portion of the LTCIS, a method to determine postdischarge needs. The LTCIS was pilot tested by Falcone and determined to be 90% reproducible.12

Two weeks postdischarge, the investigator contacted each subject by phone to complete the postdischarge interview. This interview collected information about the services provided to the patient after discharge and patient satisfaction with the process of discharge planning. Interview time was about 10 minutes.

The investigator reviewed the medical records of each patient to gather pertinent demographic information. Data analysis using descriptive statistics, analysis of variance (ANOVA), and chi-square proceeded when all data had been collected.

RESULTS

Discharge planning programs for the eight participating hospitals were organized in several ways. Although all hospitals had discharge planning guidelines and documentation policies, five hospitals (62.5%) did not have a written job description for the discharge planner, and six hospitals (75%) did not screen for high risk patients on a regular basis. Four (50%) of the hospitais routinely assessed patients at admission for discharge planning needs, and a follow-up program was present in three hospitals (37.5%) through phone calls or visits by the home health nurse. Only two hospitals (25%) formally conducted a yearly evaluation of the hospital's discharge planning program.

Table

FIGURE 2ELIGIBILITY CRITERIA FOR HOSPITALS

FIGURE 2

ELIGIBILITY CRITERIA FOR HOSPITALS

Table

FIGURE 3ELIGIBILITY CRITERIA FOR SAMPLE

FIGURE 3

ELIGIBILITY CRITERIA FOR SAMPLE

Ine hospitals were categorized according to their program structure and process for implementing discharge planning. The three hospitals with highly structured programs used the direct process for discharge planning. Of the five hospitals with less formal structuring, two used the direct process, two used the mixed approach, and one used the consultation model.

The sample in this study was older than samples used in other studies.4,6,9 The majority of this sample were married women in their late 70s who were hospitalized for about 1 week before returning home (Table 1). The high percentage of Caucasians does not reflect national statistics but is representative of rural central Texas.13 The sample had a wide variety of diagnoses, with heart failure (n = 7, 8.8%) being the most frequently reported. However, all Diagnosis Related Group assignments related to cardiovascular disorders accounted for only 15.2% of the diagnoses. A larger percentage (n = 16, 20.2%) of the sample had musculoskeletal disorders, whereas the remainder (n = 50, 64.6%) had one of 43 other diagnoses.

Provision of services and patient satisfaction variables were analyzed using ANOVA and chi-square as appropriate. The analyses revealed mat the more highly formalized structures were significantly associated with both greater provision of services and increased patient satisfaction. However, the process used for discharge planning was not significant, possibly due to the small sample of hospitals in two of the process categories. Because of this sample skew, only subjects (50) from hospitals categorized as having the direct process were entered into chisquare analysis for specific structure variables. Significant associations were exhibited between higher patient satisfaction and the structure components of the admission assessment and follow-up program. Screening showed an association at a slightly lower level (Table 2). No other structure variables were significant in the analyses.

IMPLICATIONS

This study has several implications for nurses involved in discharge planning. The findings support the use of a more structured approach for discharge planning, specifically the use of a focused admission assessment and a postdischarge follow-up program. The admission assessment, focused on discharge needs, becomes the basis for discharge planning by alerting the nurse to the patient's postdischarge needs. It also gives the patient and family time to accept that posthospital care will be needed and it gives the nurse time to arrange for that care.

Personal contacts within a short time after discharge reinforce the continuity of care concept. A follow-up program provides patients with the assurance that problems that arise after discharge from the hospital can and will be addressed. The shock and anger that many patients experience when faced with the reduced length of stay and the early return to the home may be eased by these programs. Additionally, follow-up programs give nurses immediate feedback on the effectiveness of the discharge plan. Further research is needed to test the effectiveness of specific assessment formats and protocols, as well as types of follow-up programs.

SUMMARY

This descriptive correlational study examined discharge planning programs for positive outcomes in a population of hospitalized elders. The findings indicate that there is a significant relationship between the degree of structure formality in a discharge planning program and the positive outcomes for elderly patients. Patient satisfaction and provision of postdischarge services were significantly higher for patients discharged from hospitals with a highly structured discharge planning program. Further research is needed to better delineate the variables and procedures used. Howevei; this study suggests that for the frail elderly, effective discharge planning for continuity of care can be enhanced by nurses using a carefully structured program to assess the posthospital needs and a follow-up program to solve any postdischarge problems.

Table

TABLE 1PATIENT DEMOGRAPHIC DATA

TABLE 1

PATIENT DEMOGRAPHIC DATA

Table

TABLE 2VARIABLES SUMMARY FOR SIGNIFICANT ASSOCIATIONS

TABLE 2

VARIABLES SUMMARY FOR SIGNIFICANT ASSOCIATIONS

REFERENCES

  • 1. Rossen S, Coulton C. Research agenda for discharge planning. Soc Work Health Care. 1986; 10(4):55-61.
  • 2. Smith DS, Coleman JR, Lebeda JR. Admitting, transfer, and discharge: Capturing savings from system design. Nursing Management. 1985; 16(5):25-33.
  • 3. McKeehan KM, Coulton CJ. A systems approach to program development for continuity of care in hospitals. In: McClelland K, Kelly K, Buckwalter K, eds. Continuity of Care: Advancing the Concept of Discharge Planning. Orlando, Fl: Grune & Stratton, Inc; 1985.
  • 4. Inui T, Stevenson K, Plorde D, Murphy I. Identifying hospital patients who need early discharge planning for special dispositions: A comparison of alternative techniques. Med Care. 1981;29:922-929.
  • 5. Johnson N, Fethke CC. Postdischarge outcomes and care planning for the hospitalized elderly. In: McClelland K, Kelly K, Buckwaiter K, eds. Continuity of Care: Advancing the Concept of Discharge Planning. Orlando, Fl: Gruñe & Stratton, Ine; 1985.
  • 6. Marchette L, Holloman F. Length of stay: Significant variables. Journal of Nursing Administration. 1986; 163):12-18.
  • 7. Schräger J, Halman M, Myers D, Nichols R, Rosenblum L. Impediments to the course and effectiveness of discharge planning. Soc Work Health Care. 1978;4(l):65-79.
  • 8. Arenth LM, Mamón JA. Determining patient needs after discharge. Nursing Management. 1985; 16(9):20-24.
  • 9. Lindenberg RE, Coulton C. Planning for posthospital care: A follow-up study. Health Soc Work. 1980; 5(1):45-50.
  • 10. Waters K. Discharge planning: An exploratory study of the process of discharge planning on geriatric wards. J Mv Nurs. 1987; 12:71-83.
  • 11. Starfield B. Measurement of outcome: A proposed scheme. Milbank Q. 1974; 16(5):39-50.
  • 12. Falcone AR. Development of a long-term care information system: Final report. Ann Arbor, Mi: Michigan Office of Services to the Aging; 1979. WK Kellogg Grant No. 5000.

13. National Center for Health Statistics. Utilization of short stay hospitals, United States. Annual Summary: Vital and Health Statistics Series. Washington, DC: Government Printing Office; 1983:13(83). Publication No. (PHS) 85-1744.

FIGURE 1

DISCHARGE PLANNING MODEL

FIGURE 2

ELIGIBILITY CRITERIA FOR HOSPITALS

FIGURE 3

ELIGIBILITY CRITERIA FOR SAMPLE

TABLE 1

PATIENT DEMOGRAPHIC DATA

TABLE 2

VARIABLES SUMMARY FOR SIGNIFICANT ASSOCIATIONS

10.3928/0098-9134-19910701-05

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