Discharge Planning Essay.
Discharge planning is a process that aims to improve the coordination of services after discharge from hospital by considering the patient’s needs in the community. It seeks to bridge the gap between hospital and the place to which the patient is discharged, reduce length of stay in hospital, and minimise unplanned readmission to hospital.1
Discharge planning is an established part of hospital care, but the process varies and is not entirely evidenced based. A Cochrane review analysed 11 randomised controlled trials looking at discharge planning in over 5000 patients and failed to show a reduction in mortality among elderly medical patients, lower readmission rates, or a shorter length of hospital stay.
1 However, two trials in the review did report greater satisfaction of patients and carers when discharge planning was used.2 3 The Cochrane review concluded that discharge planning remains important as a small improvement, not detected by the studies performed so far, could still yield highly significant gains in health care with huge resource implications and better use of acute hospital beds.
1 Unfortunately, none of the included trials assessed communication with primary care staff about patient transfer of care. This is an important aspect of discharge planning and another potentially important advantage for patients.
On a patient’s initial contact with health services, discharge planning should be started.4 This is often difficult to achieve when acutely unwell patients are admitted as a thorough social history may not be immediately available without a collateral history from a relative or primary healthcare provider (who may be difficult to contact). Taking a comprehensive social history is often thought to be time consuming but can be obtained quickly through the use of systematic open questions (see the four scenario boxes).
Effective discharge planning requires multidisciplinary team working. This can be difficult to coordinate because of shift work, ward transfers, staff illness, and perhaps poor team communication. To overcome this problem, an adequate handover—oral, written, or electronic—is key. Sometimes disagreements arise in the team about the most appropriate course of action, but this can usually be resolved through the involvement of a more senior member of the medical team.
Clear sensitive communication with the patient and family is pivotal, especially for the patients who experience a considerable new loss of function. Patient confidentiality cannot be neglected, however, and permission needs to be sought from a competent patient before information is divulged to a family. Relatives will sometimes disagree with the patient’s or team’s views about the most appropriate discharge destination.17 Listening to the relatives’ concerns is especially important in these situations as a compromise is often possible; however, it is the competent patient’s wishes that are paramount. Often asking patients and families for their opinion on the best and safest place to stay and then subsequently considering potential difficulties on discharge can yield the best outcome. Serious disputes should involve the consultant responsible for the care of the patient.
Handover to primary care is easily neglected as it may be perceived as low priority compared with treating unwell inpatients. Early completion of the immediate discharge document can prevent pharmacy delays, and vigilance is needed to ensure effective follow-up and handover—such as ensuring that follow-up is booked before discharge, oral information is given at handover of patients to primary care, and immediate discharge letters leave with patients
The patient’s ongoing needs must be considered and provided for before he or she leaves hospital.4 This might entail arranging appropriate follow-up (in primary or secondary care); ensuring appropriate drug treatment (with details of indications, length of course, planned dose changes); noting specific warning signs and symptoms that should prompt immediate medical attention; and ensuring adequate support at home.
A key aim of discharge planning is to provide good continuity of care to ensure good patient outcomes, hence effective handover to primary care. This is most often achieved through the immediate discharge document.13 Limited data are available on discharge documentation, but recent audits have shown that key facts and data such as follow-up arrangements, new diagnoses, and accurate medication lists are often omitted.14 15 16 The Scottish Intercollegiate Guidelines Network (SIGN) has recommended that senior staff should approve every immediate discharge document.13 Box 3 outlines the recommended minimum content for discharge documentation. In complex or unwell patients, contacting the general practitioner, community matron, or specialist nurse before discharge may be necessary to ensure an effective handover. See also the scenario box (Case study part 4).
The Department of Health guidelines suggest that preparation for discharge needs to involve health professionals, family members, social services, and the patient.4
Increasingly, the process of discharge is coordinated by the discharge coordinator (a new post in health care), who is often recruited from a nursing or social services background. Discharge coordinators provide a single point of contact for all involved in the discharge planning process.4 In some hospitals, however, this planning role may still lie principally with junior members of the medical team or the ward sister. In either case, the consultant in charge of the patient’s care has responsibility for ensuring an appropriately safe and timely discharge or transfer of care to the community.
Discharge planning requires effective multidisciplinary team working, and this is usually facilitated by weekly team meetings—which typically include medical, physiotherapy, occupational therapy, nursing, and social services professionals—to discuss each patient’s progress and the current obstacles to discharge.4 To participate fully in these meetings junior doctors need:
* A good understanding of the medical problems of the patients in their care—including prognosis, ongoing treatments, and investigations that may influence functional outcome
* An ability to communicate these points clearly
* To appreciate the clinical roles of other team members, such as anticipating which patients may require a home visit from an occupational therapist.8
Patient and family involvement
Admission to hospital is a vulnerable time for patients and their families. As a result of illness patients often experience a loss of functional ability and require either a temporary or more prolonged increase in social support.
For most patients the ideal situation is to return to their previous level of function (and their usual accommodation). However, the length of stay in an acute hospital bed is usually fairly short and may not be long enough to allow the full potential recovery of a patient. So in such a case, it must be considered whether a patient might benefit from a period of rehabilitation—either as an inpatient or in the community. Intermediate care—for patients not requiring general hospital resources but with needs outside the traditional scope of primary care—has become a popular model for delivering rehabilitation in the NHS and elsewhere.9
The involvement of patients, carers, and families is crucial to successful and timely discharge planning.4 A survey by the charity Carers UK found that 43% of the 2.3 million carers in the United Kingdom felt inadequately supported when the person returned home.10 11 Topics that carers may want to be discussed before discharge include their role as a carer, the possibility of future respite, finances, and benefits.4
A patient who has had an irreversible loss of function may require additional support at home. This could be achieved by increased care services (via social services), compensatory aids or adaptations to the home informed by an occupational therapist’s assessment, community nursing input, or through the patient’s informal care network.
Patients who can no longer manage at home may need long term care in a care home, but this should only be considered after a period of multidisciplinary rehabilitation team assessment and treatment. The process for this is outlined in the national framework for NHS continuing healthcare and NHS-funded nursing care, introduced in 2007.12
Discussing such a proposition with a patient or their family requires great sensitivity, and the decision to discharge to a new residence is one that requires senior input. However, junior doctors often play an important role in collecting information that helps inform decision making, and box 2 gives some useful questions to ask the patient when making this decision; see also the scenario box (Case study part 3).