Research has indicated that effective discharge planning reduces patient readmission to hospital. By critically analysing the practice of discharge planning from the acute care sector, the factors which contribute to effective discharge planning can be identified. Furthermore, by employing these key factors, an evidence based discharge plan can be produced for a person suffering the effects of drug and/or alcohol abuse.
For many patients, getting ready to leave the hospital is one of the most critical aspects of their hospital stay. According to Moss, Flower & Houghton (2003), recent studies have shown that careful discharge planning, along with good follow up contact can significantly improve patients' health upon discharge, while decreasing health care and social costs, and readmission rates. Referral to community based organisations as part of the discharge plan helps reduce the rate of functional decline and repeat presentation to hospital. Additionally, proper planning for departure from the hospital can make all the difference in patients' long term prognosis - because it encourages them to get involved in managing their own care.
Thus with discharge planning - patients can maintain a level of health and improve it.
A recent study by McKenna, Keeney, Glen & Gordon (2004) compared the results of patients receiving discharge planning with those who did not. The focus was on medication, symptom management, diet, activity, sleep, medical follow up, and the emotional status of patients and their care givers. By 24 weeks after discharge, only 20 percent of those following a discharge plan had been re-hospitalised, compared with 37 percent of those who did not. The intervention group also had fewer hospital days and about half the total health service costs as the control group.
The practice of discharge planning ion the acute care sector and key factors that contribute to successful discharge
Today hospitals are discharging patients earlier than ever. Shorter hospital stays have placed increased demands on home nursing services and other community based organisations. The need for a coordinated approach to discharge planning, and good liaison between hospitals and community based organisations - are crucial in ensuring that clients receive optimal care. According to Bristow (2001: 1439) "When patients receive adequate discharge planning, they usually recover faster at home. Also with less time spent in hospital, their chances of developing a nosocomial infection are greatly reduced. And compared with hospital care, home care is much less costly for everyone involved."
Various organisations in the acute care setting have different guidelines for safe and effective discharge planning. By critically analysing the practice of discharge planning, the key factors that contribute to successful discharge can be determined. In general terms, the key principles of discharge planning can be put under the following headings:
* Case finding
According to Mahoney, Doyle, and Coutler (2000) - who reported their findings in the Australian Nursing Journal, discharge planning should begin on or before admission. When taking a patients history, staff need to be alert to any potential or possible problems which may affect home care needs. Some of the main things to consider are:
* Age - Is the patient too young or too old to care for themselves?
* Diagnosis - Has the patient been recently diagnosed with a debilitating or terminal condition?
* Primary care giver - Is the person responsible for the patient able to care for them?
* Personal limitations - Does that patient have a secondary condition that prevents him/her from taking care of their self?
* Nutritional status - Does the patient have special dietary needs? Will they need assistance preparing meals?
* Other health risk factors which need to be identified and may relate to a clients ability to cope at home can include:
Deteriorating cognitive status
An unsafe home environment
Repeated hospital admissions
Non compliance or lack of knowledge of medication
Language or cultural factors
End stage illness
Complex technical care
Mahony, Doyle, and Coulter go on to state that assessment commences using information form clinical records, discussions with multidisciplinary team members, and interviews with the potential client and their primary carer. This assessment can be used to identify client/carer needs and draw up a provisional discharge plan.
"As your patient's hospital stay progresses, you'll need to review his/her condition and adjust your discharge plan accordingly. Also during this time, discuss the patients discharge goals and needs with the health care team. In this way, community agencies can be contacted and a home care plan implemented." Steagall (1997: 14).
All communication needs to be documented in the client's hospital record and communicated to members of the multidisciplinary team. This is a good time to arrange referrals to other community providers and to arrange case conferences if there are complex issues involved with the client's care.
Around this time, home care issues also need to be examined. "Begin home care teaching as soon as the client seems receptive. Whether this home care will be long or short term, be sure to design your teaching to fit the client goals. You'll need to provide family members with clear and concise instructions for ongoing care at home. And ensure to give the home care agency copy of your care plan.
On the day of discharge, be sure to check back with the health care team to see if all plans have been made, for example:
* Are medical supplies in the patient's home or on their way?
* Has a nurse or home health aid been scheduled to come to the home?
* Will the patient need medically equipped transportation?
By double checking these details before the patient leaves the hospital, you can spare the client and family unnecessary anxiety later. (Mahoney, Doyle & Coutler, 2000).
Once at home
The discharge planning process continues once the client is at home. Clients should be contacted within 24 hours of receiving the referral to organise a visit time, and to ensure all the necessary equipment is in place to enable an assessment nurse to adequately assess the client's needs in the home environment.
Mahoney, Doyle & Coutler (2000) state that an initial assessment conducted by an experienced assessment nurse builds on the comprehensive assessment initiated prior to this - and leads to the development of a discharge plan with measurable outcomes and time frames. The plan of course is formulated with the client and family with an end view of promoting an optimal level of health for the client. The team approach for the individual client needs to be outlined.
The assessment nurse needs to liaise with other service providers to ensure that all the client's needs are being met. Major community health services generally fall under the categories of:
* Aged Care
* Community Nursing
* Community Midwifery Counselling
* Drug & Alcohol Services
* Early Childhood Services
* Youth Services
* Family Care
* Health Education & Promotion
* Mental Health
* Palliative Care
* Allied Health Services
Hicks & Ashley (2001: 36) sum up the goals of effective discharge planning in the acute care sector with what they call lithe M.E.T.H.O.D. method where:
M stands for medication
E stands for environment
T stands for treatments
H stands for health teaching
O stands for out patient referral
D stands for diet
The goal here is for the patient and/or carer to know his/her medications names, purposes, and effects. He/she should know what dose to take, how often, what precautions to take, and the symptom of possible side effects which need to be reported.
The goals here are for the patient to be given adequate homemaking services, emotional and economic support, and transportation to clinics when necessary. Their home environment needs to be assessed and appropriate modifications made.
The goal here is for the patient and/or carer to know the purpose of any continuing treatments and be able to demonstrate the correct technique, and report any problems.
The goal here is for the patient and/or carer to be able to describe how his/her disease/condition affects function, describe the keys to health maintenance, and name the signs and symptoms that require medical attention.
The goal here is for the patient to know when and where to keep clinic appointments and who to call for medical help. The patient and all referral agencies will have discharge instruction sheets.
The goal here is the patient and/or carer to be able to describe his/her diet and its purpose.
Although the M.E.T.H.O.D. method is concise and great ways to summarise the main goals of effective discharge planning, Hicks & Ashley (2001: 36) go on to outline the following points:
Factors influencing positive outcomes
* Discharge planning that commences on or prior to admission to hospital
* Effective communication between the client/carer hospital staff and community resources
* Client/carer participation
* Multi-disciplinary team approach
* Expert assessment
* Continuity of care following discharge form hospital
Principles for planning discharge
* If faxing information to community services, always follow up with a phone call to ensure information has been received and understood
* Ensure demographic details are correct
* Check and modify the home environment so that clients can perform their activities of daily living with maximum independence
* Ensure clients have medication supplies and are able to administer. If referred to a community service for medication administration, ensure orders are forwarded prior to the client's first visit.
* Instigate referrals to appropriate community health services to maximise outcomes
Evidence based discharge plan for a person suffering from drug and/or alcohol problems
By comparing and contrasting different methodologies for discharge planning, a guide to an evidence based discharge for a person suffering drug and/or alcohol problems can be surmised as follows:
Planning needs to begin on or before admission. Here factors commonly associated with substance abuse need to be taken to be taken into account (for example):
* The increased incidence of sexually transmitted diseases
* The increased incidence of blood born diseases transmitted sexually or by IV drug use including HIV an Hepatitis
* Problems with liver function
* Impaired mental state
* Mental illness and drug psychosis
* Risks of self harm
* Impaired nutritional status
* Impaired hygiene and other activities of daily living
From here, an assessment needs to be conducted using information from clinical records, and client/carer interviews. From here discharge goals can start to be identified. These may include:
* Improvement of coping skills
* Identifying relapse risks - including people, places and things that can interfere with sobriety. Ways of handling these on discharge need to be considered.
* Changes to environmental variables need to be identified and plans put in place to modify them before discharge.
* The patient's physiologic feelings and sensations need to be identified and methods for handling them on discharge put into place.
* The primary carer/family need to be interviewed to outline the part they play in the ongoing recovery of the patient both before and after discharge.
* Pharmacologic interventions, self maintenance strategies, as well as support and self help groups need to be identified.
At this point, arrangements need to be put in place for the role of community health groups after discharge. These may include:
* Community medical services
* Aftercare such as supervised living if necessary
* Individual, family or group therapy resources, psycho-educational groups, as well as support and self help groups (for example):
* Alcoholics Anonymous
* Narcotics Anonymous
* Community drug centres
* Supports groups such those in NSW including - the Anglicare Drug & Alcohol Service, Wesley Mission, Salvation Army
* Anger management groups
Final checks need to be put in place with the multidisciplinary team and health care organisations to ensure adequate support is available for the patient on discharge. Community health services need to be called to re-check availability and referral dates. Accommodation for example (Sydney Community Housing) may need to be called to verify dates and availability.
Once at home
Once the client has been discharged home, he/she needs to be contacted within 24 hours to organise a visit time to ensure all equipment is in place - to enable an assessment nurse or occupational therapist to assess needs in the home environment. Checks should also be made on the carer/family at this point and arrangements made for ongoing counselling if required. Again organisations like Anglicare, Wesley, the Salvation Army, and local health services (for Sydney residents) provide necessary services to recovering alcohol/drug users and their carers/family.
The benefits of effective discharge planning can clearly be illustrated. By critically analysing the practice of discharge planning, best methods can be determined to formulate an evidence based discharge plan for clients such as those suffering drug and/or alcohol abuse. It is essential for nurses to acquire a background in effective discharge planning to enable them to provide adequate care to clients.
Bristow, O., Making the moves in discharge planning, American Journal of Nursing, 2001:79:1439
Hicks, A. & Ashley, D., Teaching Discharge Planning. Nursing Outlook, 2001:24:306
Mahoney, A., Doyle, A., & Coulter, C., Coordinating Hospital Discharge, Australian Nursing Journal, 2000 Vol 8: Issue 1
McKenna, H., Keeney, S., Glenn, A., Gordon, P., Discharge planning: an exploratory study. Journal of Clinical Nursing, 2004:9:594-601
Moss, J., Flower, C., Houghton, L., Improving Emergency Department Discharge Planning Practice. Medical Journal of Australia, 2003:178(3):109-110
Smith, J., Making the right moves in discharge planning. American Journal of Nursing, 2004:79:1439
Stegall, B., How to prepare your patient for discharge planning, Nursing, 1997:7:14