This chapter provides important information about the literature that is associated with discharge matters, which may result in negative or positive health outcomes among patients across the world. It is essential to point out that the first sections of the literature review will focus on concepts of discharge planning that offer a background. The background information would be used to influence the bed capacity in the delivery of healthcare services. Discharge planning is defined as a collection of activities within the healthcare sector that promote the ways in which a patient is released from one hospital to another or from a hospital to home. The process is typified by members from multiple disciplines, such as physicians, nurses, and pharmacists. The main goal of the process of discharge planning is to facilitate continuity of care. From a clinical point of view, the process starts on admission (Charlesworth & Mckenzie, 1996). Bull (2000) argues that hospital discharge process is bounded by different periods of stays of patients in healthcare facilities. For effective planning to be achieved, appropriate arrangements should be made for and offered to healthcare consumers to cater for their needs in the context of continual care upon being released from hospitals. Due to the fact that the concept was conceived to improve the welfare of patients with different needs, it combines many aspects, such as medical and financial resources. A person can only be allowed to go home if his or her health outcomes are found to be excellent. Otherwise, he or she would be referred to another facility that would offer better care. As a result, inpatient stays in hospitals can be reduced significantly, which correlates with substantial savings of care costs (Charlesworth & Mckenzie, 1996, Newby, 1996).
Nonetheless, it has been established that a significant number of patients remains in care facilities in cases where there are no better hospitals to offer the necessary care. The elderly patients account for the majority of those admitted to care facilities. Particularly, those aged 65 and over represent about thirty-eight percent of stays in hospitals. Among all the days spent by the sick in care facilities, the elderly people take about 44%. It is worth to note that the percentage represents a significant increase (24%) since 1970. The management teams should always strive to address the needs of ever increasing patient population with relatively short periods of inpatient stays.
A remarkable number of patients are Medicare beneficiaries (13 million), but patients receive low-quality services due to the fact that hospitals do not have adequate resources. In addition, discharge planners have inadequate time to efficiently determine patients who require urgent post-acute care. This could result in increased chances of developing risks that lead to costly experiences of poor outcomes by patients. When there is inadequate time for identification of patients who require urgent care, then they cannot obtain beneficial services. However, studies have shown that there is a lack of equivalence between experts and decisions that are made in the context of referring patients to post-acute care (PAC). For example, Bowles (2008) shows that in cases where patients have risks, they would most likely be referred to other care centers by clinical experts. However, hospital clinicians rarely refer patients for specialized treatments. A significant number (74%) of referred cases was suggested to access home care, but the remaining 26% of the patients could not attain the appropriate care due to misunderstanding of care providers. Thus, it would be critical for care providers to assess patients thoroughly with the goal of identifying those in need of home care, which has high chances of enabling patients to attain improved outcomes.
In the recent past, two national reviews have been conducted with regard to discharge planning. However, there are no large-scale studies that have been carried out to assess how PAC decisions are made in hospitals. Furthermore, no study has been conducted to describe how evaluations are translated into clinical judgments with regard to the requirements for post-acute referrals. Over the years, scholars and managers in the healthcare sector have not developed decision support tools that could be applied nationally in the process of making important judgments. There is a tendency among care providers to gather criteria from various sources and apply them in an appropriate manner. For example, many professionals do not consider factors, such as the environment and finances, which could have great impacts on the process of treating patients. Thus, assessments should be done while taking into account many patient and external factors.
Naylor et al. (1994, 1999) have developed a broad program to support practice nurses when they are making discharge decisions. The program involves a detailed needs assessment and formulation of an effective discharge plan. For the program to be utilized, members from various disciplines within a hospital should cooperate and communicate efficiently. It is also typified by follow-ups that are in the forms of telephone calls or visits to care homes. The approach has been shown to result in significant reductions in inpatient stays and remarkable improvements of care outcomes among patients. It is notable that the comprehensive program has led to reduced frequencies of patient admissions and lowered medical costs. Based on the study by Charlesworth and Mckenzie (1996, p. ), “the discharge planner is usually from the nursing staff, and can either be the patient primary nurse, the nurse in charge of the unit”, or the case manager.
Some national organizations that specialize in the quality of care have developed terms and definitions in the context of discharge planning. The most important platform of supporting hospital discharge planning, which is intended to improve care outcomes, demonstrates that discharge planning encompasses a set of interventions that is impacted by admission and discharge events. In addition, the platform shows that discharge planning could involve events that have no clear signals that correspond to start and stop points. Coordination of care is a feature of that is essential to discharge planning and intermediary care, but should not be considered an intervention to help patients. The chief goal of a discharge planner is to ensure that there is stability of the quality of care, which is achieved by involving family members and referring patients to centers where they could receive post-acute care in a timely manner.
Effectiveness of discharge planning
Research has demonstrated that discharge planning initiated by nurse case managers achieve their goals by ensuring that instructions are followed, follow-ups are adopted, and post-discharge accommodations are implemented (Lin, Wang, Chang, & Yang, 2005). If a discharge plan is screened early, then there is an increased likelihood of reducing inpatient stay periods. The extent to which discharge planning attains its objectives is “assessed by determining the patient’s readmission rate, the frequency of emergency visits, length of hospital stay, and patient satisfaction with discharge planning” (Lin et al., 2005, p. ).
Early screen for discharge planning
As aforementioned in this literature review, the elderly patients are most impacted by discharge planning across the world. It has been shown that there are delays when discharging older patients from care centers. The delays could be attributed to the absence of options in relation to acute care, tardy discharge planning, lack of competence in post-acute care, limited funds, and workforce constraints, just to mention a few. It has been shown that many patients experiencing discharge delays are those waiting to be placed in preferred homes. In the United Kingdom, many facilities do not have the capacity to act as alternative centers for patient referrals. This is one of the leading factors that are responsible for delayed discharge cases.
To avoid problems in relation to discharge planning, the management teams in healthcare institutions should commence early discharge and assessment processes. The processes should map older persons’ pathways via care to discover bottlenecks. This could involve the involvement of patients and their care providers at the time of discharge. In addition, inpatient stays should be monitored to reduce their lengths and enhance services of organizations. Effective discharge planning is beneficial to the events of recovering from injury and readmissions. In fact, discharge planning has been demonstrated to reduce lengths of inpatient stays among the elderly. The approach is critical in an era that is typified by many financial constraints across the world. Personnel at Montreal General Hospital have determined patient populations that require two types of resources, i.e., new and alternative resources. Other types of patient groups identified are those that have disorganized patients, palliative patients, and those waiting to be transferred to home centers to receive long-term care (Tennier 1997).
A study has shown that many cases (about 30%) of delayed discharges occur on nonmedical grounds. The US Department of Health, in 2003, stated that discharge delays were caused by many factors, such as inadequate evaluations, leading to late booking of transport and poor knowledge of social contexts of patients and their families. Shepperd and colleagues (2003) contend that effective strategies of communication between a discharge planner and caregivers in external environments are important. The study authors also note that even small reductions in periods of inpatient stays or frequencies of readmissions can significantly increase the capacity of facilities, especially in situations where are limited acute hospital beds.
In eighty “hospitals in North Carolina, the mean delay of 3,111 patients waiting to be discharged from acute to sub-acute care was 16.7 days” (Falcone et al., 1991, p. ). The study by Falcone and colleagues (1991) established that when patients are delayed from being discharged, they are most likely to experience poor quality care outcomes. Delays could be used to assess the extent to which hospitals fail to coordinate services and provide unique care to clients. The researchers also note that most of the disadvantaged facilities were found in urban centers that did not have capacity to help heavy-care persons who did not require continued acute care, but they spent considerable periods on hospital beds. It is worth to note that the beds could be used to cater for more demanding cases.
Regarding Australia, NSW Health adopted a framework in 200 that could go a long way in facilitating effective discharge from care facilities. The policy recommended the adoption of a discharge risk assessment instrument, which could be used to determine patients at risk of experiencing discharge delays. Furthermore, the framework contains a plan that is exemplified by estimated dates of discharge. It is important to tell patients the period they would spend in hospitals in advance for booked surgery. A review of experiences of patients who underwent elective “carotid surgery did not correlate patients’ perceptions of readiness for discharge with preparation through pre-admission clinic consultations” (Middleton et al., 2004, p. ). Middleton and colleagues (2004) found that post-discharge communication approaches with general practitioners were relatively poor. In fact, not even half of the study participants reported having received a discharge summary from their general practitioners within a fortnight. However, letters from surgeons were found to be more helpful than discharge summaries. The study authors predict that, in the near future, many hospitals would adopt electronic discharge referral systems that would be supported by the relatively high rates of advancements in the field of information technology (Middleton et al., 2004).
Outcomes
This chapter provides a detailed review of outcome aspects that offer a background, which would impact patient outcomes in the delivery of healthcare. Effective healthcare organizations aim at obtaining their goals. In the context of nursing practice, effectiveness can be viewed as a measure of care outcomes, which can be used to assess the extent to which an organization performs its functions. Patient outcomes could be used to reflect specific conditions, for example, those that are important in some diseases, such as cancer. In addition, outcomes could be applied to describe global aspects in nature, which are essential for evaluations in the healthcare systems. Some examples of global outcomes include measures of quality of life and contentment with healthcare.
Donabedian (1990) notes that to assess a firm’s level of effectiveness and quality of services, it is critical to evaluate many factors, such as optimality, legitimacy, and equity. Contemporary concentration to evaluate effectiveness levels of institutions in the healthcare sector is on outcome measures. In this context, “organizational effectiveness can be evaluated at three levels, which are individual, group, or organizational levels” (Donabedian,1990, p. 1115). However, they are interdependent. When an individual wants to determine the efficiency of the results, he or she should be assured that it is a pertinent gauge of quality. At the level of the organization, results are important tools to assess its effectiveness, and they are reported as a collection. One merit of organizational level results is that they offer a platform on which an evaluation of a firm’s inputs and processes are assessed. In this study, patient outcomes are in relation to the functional significance, the number of beds, periods of inpatient stays.
Healthcare outcomes can be “defined as a change in the patient’s health status between two or more time points” (Shaughnessy, 2002, p. 1364). The main goal of healthcare facilities is the attainment of excellent care outcomes. In the context of health care settings, personal results of patients are assessed in terms of changes in persons’ status in the event that an episode of care is initiated. Literature shows that some of the common outcomes that have been studied are hospitalization rates, utilization of emergent care, and alterations in functional wellbeing. A recent study has established that important features of patients are more likely to contribute to patient results. Some of these are age and level of disability (cite here). Adverse outcomes are associated with unmet care needs (Mistiaen et al., 2007). Assessment methods and approaches to making decisions require that adverse results should be accurately identified after discharge (Bowles et al. 2003). Another important concept in this context is end result outcomes, which imply the changes that are experienced by patients over time. Aspects of admission and discharge may be applied to know end result outcomes.
Functional status is an essential aspect of patient outcomes, which is commonly used to evaluate nursing care (Mitchell et al., 1997). Functional status is assessed by determining the level of independence of ADLs and events that are important in determining outcomes in care homes. Thus, it can be stated that functional status in essential for facilitating independence. Regarding nursing practice, functional status could enable nurses to be more responsible for helping patients to stabilize and significantly improve their biological functions (Naylor, Munro, & Brooten, 1991). Several studies have been conducted to assess the importance of functional status on patient outcomes. For example, Christensen, Doblhammer, Rau & Vaupel (2009) have shown that there is a significant correlation between the utilization of post-acute care and outcomes of patients, which are in the form of functional status. On the other hand, Saad and colleagues (2010) there is not remarkable association between post-acute care and better patient outcomes. Based on the contradicting findings, it would be important to suggest that more studies need to be conducted to more insights into the subject matter.
Mental health status of the elderly has been recognized as essential outcomes in the healthcare sector. A mental disorder can be defined as a behavioral anomaly that causes impaired abilities to function in a normal manner. However, in nursing practice, it is generally accepted that mental disorders do not have social and/or development basis. The elderly patients are evaluated for mental disorders on the grounds of how they feel, think and act. In most cases, they are associated with malfunctioning of the nervous system (Bruce, Seeman, Merrill, & Blazer, 1994; Bruce et al., 2002; Lebowitz et al., 1997).
Instrumental outcomes refer to changes that are evident in the patient’s emotions and knowledge, which can impact his or her healthcare outcomes. Some of the outcomes are “increased patient knowledge, satisfaction with care, or compliance” (Shaughnessy et al. 1997, p. 120). Instrumental outcomes can be used to evaluate end-result outcomes. That notwithstanding, a significant number of studies has found that the type of outcomes is the most difficult to assess. Research in the future may focus on creating novel methods that would be essential in facilitating the ease with which instrumental results would be measured.
Utilization outcomes “imply the adoption of other services in addition to healthcare centers” (Shaughnessy et al., 2002, p. 1164 ). An example of the outcomes is the use of emergency care within healthcare facilities, which could lead to better healthcare results among patients. They are applied by researchers to reflect on the negative impacts of health status. Furthermore, they are utilized in home healthcare studies due to the fact that they are easily measured.
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