Illuminating hospital discharge planning: staff nurse decision making

Nurses' Roles, Responsibilities and Actions in the Hospital Discharge Process of Older Adults with Health and Social Care Needs in Three Nordic Cities: A Vignette Study

The hospital discharge process of older adults in need of both medical and social care post hospitalisation requires the involvement of nurses at multiple levels across the different phases. This study aims to examine and compare what roles, responsibilities and actions nurses take in the hospital discharge process of older adults with complex care needs in three Nordic cities: Copenhagen (Denmark), Stockholm (Sweden) and Tampere (Finland). A vignette-based interview study consisting of three cases was conducted face-to-face with nurses in Copenhagen (n = 11), Stockholm (n = 16) and Tampere (n = 8). The vignettes represented older patients with medical conditions, cognitive loss and various home situations. The interviews were conducted in the local language, recorded, transcribed and analysed thematically. The findings show that nurses exchanged information with both healthcare (all cities) and social care services (Copenhagen, Tampere). Nurses in all cities, particularly Stockholm, reported to inform, and also convince patients to make use of home care. Nurses in Stockholm and Tampere reported that some patients refuse care due to co-payment. Nurses in these two cities were more likely to involve close relatives, possibly due to such costs. Not accepting care, due to costs, poses inequity in later life. Additionally, organisational changes towards a shift in location of care, i.e., from hospital to home, and from professional to informal caregivers, might be reflected in the work of the nurses through their initiatives to convince older patients to accept home care and to involve close relatives.

Health professionals' experience of implementing and delivering a 'Community Care' programme in metropolitan Melbourne: a qualitative reflexive thematic analysis

OBJECTIVES

To explore the experiences of health professionals involved in delivering a multidisciplinary Community Care programme that provides a transitional care coordination service for patients visiting a tertiary hospital service in Melbourne, Australia.

DESIGN

Reflexive thematic analysis was used to identify themes from descriptions of delivering the programme, including its perceived strengths and challenges.

PARTICIPANTS

12 healthcare professionals from four disciplines working in the Community Care programme were interviewed.

RESULTS

Four themes were identified: (1) 'increasingly complex', depicts the experience of delivering care to patients with increasingly complex health needs; (2) 'plugging unexpected gaps', describes meeting patient's healthcare needs; (3) 'disconnected', explains system-based issues which made participants feel disconnected from the wider health service; (4) 'a misunderstood programme', illustrates that a poor understanding of the programme within the health service is a barrier to patient enrolment which may have been exacerbated by a service name change.

CONCLUSIONS

The healthcare professionals involved in this study described the experience of providing care to patients as challenging, but felt they made a positive difference. By unravelling the patients' health problems in context of their surroundings, they were able to recognise the increasingly complex patients' health needs. The disconnection they faced to integrate within the wider healthcare system made their role at times difficult. This disconnection was partly contributed to by the fact that they felt the programme was misunderstood.

Clinicians' Attitudes and System Capacity Regarding Transitional Care Practices Within a Health System: Survey Results From the Partners-PCORI Transitions Study

OBJECTIVES

Successful efforts to improve transitional care depend in part on local attitudes, workload, and training. Before implementing a multifaceted transitions intervention within an Accountable Care Organization, an understanding of contextual factors among providers involved in care transitions in inpatient and outpatient settings was needed.

METHODS

As part of the Partners-Patient-Centered Outcomes Research Institute (PCORI) Transitions Study, we purposefully sampled inpatient and outpatient providers within the Accountable Care Organization. Survey questions focused on training and feedback on transitional tasks and opinions on the quality of care transitions. We also surveyed unit- and practice-level leadership on current transitional care practices. Results are presented using descriptive statistics.

RESULTS

Among 387 providers surveyed, 220 responded (response rate = 57%) from 15 outpatient practices and 26 inpatient units. A large proportion of respondents reported to have never received training (50%) or feedback (68%) on key transitional care activities, and most (58%) reported insufficient time to complete these tasks. Respondents on average reported transitions processes led to positive outcomes some to most of the time (mean scores = 4.70-5.16 on a 1-7 scale). Surveys of leadership showed tremendous variation by unit and by practice in the performance of various transitional care activities.

CONCLUSIONS

Many respondents felt that training, feedback, and time allotted to key transitional care activities were inadequate. Satisfaction with the quality of the transitions process was middling. Understanding these results, especially variation by location, was important to customizing implementation of the intervention and will be key to understanding variation in the success of the intervention across locations.

Hospital to Home: Supporting the Transition From Hospital to Home for Older Adults

Background

An increasing proportion of older adults experience avoidable hospitalizations, and some are potentially entering long-term care homes earlier and often unnecessarily. Older adults often lack adequate support to transition from hospital to home, without access to appropriate health services when they are needed in the community and resources to live safely at home.

Purpose

This study collaborated with an existing enhanced home care program called Home Again in Nova Scotia, to identify factors that contribute to older adult patients being assessed as requiring long-term care when they could potentially return home with enhanced supports.

Methods

Using a case study design, this study examined in-depth experiences of multiple stakeholders, from December 2019 to February 2020, through analysis of nine interviews for three focal patient cases including older adult patients, their family or friend caregivers, and healthcare professionals.

Results

Findings indicate home care services for older adults are being sought too late, after hospital readmission, or a rapid decline in health status when family caregivers are already experiencing caregiver burnout. Limitations in home care services led to barriers preventing family caregivers from continuing to care for older adults at home.

Conclusions

This study contributes knowledge about gaps within home care and transitional care services, highlighting the importance of investing in additional home care services for rehabilitation and prevention of rapidly deteriorating health.

The "hard, relentless, never-ending" work of focusing on discharge: a qualitative study of managers' perspectives

PURPOSE

Interventions to hasten patient discharge continue to proliferate despite evidence that they may be achieving diminishing returns. To better understand what such interventions can be expected to accomplish, the authors aim to critically examine their underlying program theory.

DESIGN/METHODOLOGY/APPROACH

Within a broader study on patient flow, spanning 10 jurisdictions across Western Canada, the authors conducted in-depth interviews with 300 senior, middle and frontline managers; 174 discussed discharge initiatives. Using thematic analysis informed by a Realistic Evaluation lens, the authors identified the mechanisms by which discharge activities were believed to produce their impacts and the strategies and context factors necessary to trigger the intended mechanisms.

FINDINGS

Managers' accounts suggested a common program theory that applied to a wide variety of discharge initiatives. The chief mechanism was inculcation of a sharp focus on discharge; reinforcing mechanisms included development of shared understanding and a sense of accountability. Participants reported that these mechanisms were difficult to produce and sustain, requiring continual active management and repeated (re)introduction of interventions. This reflected a context in which providers, already overwhelmed with competing demands, were unlikely to be able (or perhaps even willing) to sustain a focus on this particular aspect of care.

ORIGINALITY/VALUE

The finding that "discharge focus" emerged as the core mechanism of discharge interventions helps to explain why such initiatives may be achieving limited benefit. There is a need for interventions that promote timely discharge without relying on this highly problematic mechanism.

Nurses' heart failure discharge planning part II: Implications for the hospital system

AIM

The purpose of this interpretive descriptive study was to understand bedside nurses' motivation and decision-making during discharge planning for patients with HF on a 48-bed telemetry unit.

BACKGROUND

Heart failure (HF) discharge planning interventions have largely excluded the contributions of bedside nurses.

METHODS

Fifteen nurses were interviewed. Coding was done using NVivo and thematic analysis was completed.

RESULTS

This paper is the second in a two-part series which presents separate results of one interpretive descriptive study delineating the factors that impact bedside nurses' HF discharge planning. This paper presents how nurses' lack of time, competing priorities, and hospital policies affect nurses' HF discharge planning. In addition to the previous report (part I) of how nurses felt more motivated during HF discharge planning when they had time to establish a personal connection with patients, nurses reported being motivated when they had time to individualize HF education and did not feel rushed to complete discharge planning tasks.

CONCLUSIONS

Findings from this study suggest that patients with HF may benefit if bedside nurses are afforded the support to effectively assess patients' discharge needs and educate them. A shift in organizational practice is needed, such as employing HF nurse educators to lead bedside nurses in a more structured method of HF education delivery, requiring discharge planning as a component of each shift's work, and promoting bedside nurse involvement in HF discharge planning decision-making within interdisciplinary teams.

Nurses' heart failure discharge planning part I: The impact of interdisciplinary relationships and patient behaviors

AIM

The purpose of this interpretive descriptive study was to understand bedside nurses' motivation and decision-making during discharge planning for adult patients with HF on a 48-bed telemetry step-down unit.

BACKGROUND

Heart failure (HF) discharge planning interventions have largely excluded the contributions of bedside nurses.

METHODS

Fifteen bedside nurses were interviewed. Coding was done using NVivo and thematic analysis was completed.

RESULTS

This paper is the first in a two-part series which presents separate results of the interpretive descriptive study delineating the factors that impact bedside nurses' motivation and decision-making during HF discharge planning. This paper presents the major finding of nurses' high levels of motivation to do effective discharge planning despite many barriers, such as poor physician-nurse communication and patient behaviors. These nurses described being motivated when they had good communication from the interdisciplinary team and time to establish a personal connection with patients.

CONCLUSIONS

Overall, findings of this study emphasized a need for interdisciplinary relationship-building between bedside nurses, patients, and physicians to be factored into the organizational culture.

Parent Readiness for Hospital Discharge Scale: Psychometrics and Association With Postdischarge Outcomes

INTRODUCTION

The purpose of this study is to validate the Readiness for Hospital Discharge Scale (RHDS) for use with parents of hospitalized children. PedRHDS is a structured tool for a discharge readiness assessment before pediatric discharge.

METHODS

Using combined data from four studies with 417 parents, psychometric testing and item reduction proceeded with principal component analysis for factor structure delineation, Cronbach's alpha for reliability estimation, and regression analysis for predictive validity.

RESULTS

A 23-item PedRHDS retained the a priori factor structure. Reliability ranged from 0.73 to 0.85 for the 23-item and 10- and 8-item short scales. PedRHDS (all forms) was associated with postdischarge coping difficulty (explaining 12%-16% of variance) and readmission (odds ratio = 0.71-0.80).

DISCUSSION

The PedRHDS and both short forms (PedRHDS-SF10 and PedRHDS-SF8) are reliable and valid measures of parental discharge readiness that can be used as outcome metrics of hospital care and risk indicators for postdischarge coping difficulty and readmission.

Are we "missing the big picture" in transitions of care? Perspectives of healthcare providers managing patients with unplanned hospitalization

BACKGROUND

Healthcare providers play a critical role in the care transitions. Therefore, efforts to improve this process should be informed by their perspectives.

AIM

The study objective was to explore the factors that negatively/positively influence care transitions following an unplanned hospitalization from the perspective of healthcare providers.

METHODS

A qualitative study using semi-structured interviews conducted between February and September of 2016 at a single academic medical center. We enrolled fifteen healthcare providers from multiple disciplines involved in the management of patients experiencing an unplanned hospitalization. Respondents shared their experiences with care transitions and identified factors within and outside of the discharging health facility that impede or facilitate this process. Transcribed interviews were analyzed using emerging themes from the interviews.

RESULTS

We identified six themes and associated subthemes from the interviews on factors that influence care transitions. Three themes focused on factors within the discharging healthcare facility: untailored and overloaded patient discharge information, timing of the post-discharge care conversation, provider-to-patient and provider-to-provider miscommunication. The other three themes were related to external factors including caregiver involvement, having a safe and stable housing environment, and access to healthcare and community resources. Providers discussed how these factors positively/negatively influence the hospital-to-home transition.

CONCLUSIONS

Our study identifies factors within and outside the discharging healthcare facility that influence care transitions, ultimately affect patient-centered outcomes and provider satisfaction with delivered care. Strategies aimed at improving the quality of care transitions should address these barriers and actively engage healthcare providers who are pivotal in care transitions.

Effect of the programme Plan de egreso on chronically ill patients and their family caregivers

OBJECTIVE

To determine the effect of the programme Hospitalisation discharge plan for patients with chronic diseases and family caregivers to strengthen their home care competence -CUIDAR- and reduce the caregiver burden.

METHOD

Quasi-experimental study approach with intervention group. Participants were 62 patients and their caregivers who consulted with a health care institution in the city of Girardot (Colombia). The intervention was carried out for one month, during which, measurements were performed before and after the programme.

RESULTS

Most patients were elderly, diagnosed with diabetes, hypertension or COPD, 35% of them with some degree of dependency. The caregivers were mostly women, between the ages of 35 and 59 years old, domestic caregivers, and responsible for caring for their patients for between 13-24hours a day. At the start of the programme the competency for care was low in both patients and caregivers, after the intervention there was a general increase in care and a statistically significant change. Also, at the beginning, 48% of caregivers had some level of burden, and after the study only 27% reported burden with care.

CONCLUSIONS

The Hospitalisation discharge plan is a strategy that increases the home care competency of the patient and the caregiver, and decreases the caregiver burden.

Care transitions: a systematic review of best practices

This article reports results from a systematic review used to inform the development of a best practice guideline to assist nurses in understanding their roles and responsibilities in promoting safe and effective client care transitions. A care transition is a set of actions designed to ensure safe and effective coordination and continuity of care as clients experience a change in health status, care needs, health care providers, or location.

Rapid discharge from hospital in the last days of life: an evaluation of key issues and the discharge sister role

BACKGROUND

When the time comes, most people wish to die at home. Nevertheless, many deaths occur in hospital, often because of delays in the discharge process. This study explored the issues surrounding rapid discharge from hospital in the final days of life, and evaluated the contribution of a discharge sister role.

METHODS

A qualitative design was used, incorporating focus groups and interviews with key stakeholders. A total of 75 staff and 7 carers participated.

RESULTS

Participants highlighted the small window of opportunity available to facilitate a rapid but safe discharge from hospital. Early recognition of the last days of life was vital as was the availability of a skilled health professional, such as the discharge sister, to coordinate the patient's journey from hospital to preferred place of death.

CONCLUSIONS

Rapid discharge is challenging and requires high levels of skill. The discharge sister navigated complex organisational systems to facilitate rapid discharge for those who might otherwise have died in hospital.

[Redesigning the hospital discharge process]

OBJECTIVE

The aim of this article is to show that the redesign and planning process of hospital discharge advances the departure time of the patient from a hospital environment.

MATERIAL AND METHOD

Quasi-experimental study conducted from January 2011 to April 2013, in a local hospital. The cases analysed were from medical and surgical nursing units. The process was redesigned to coordinate all the professionals involved in the process. The hospital discharge improvement process improvement was carried out by forming a working group, the analysis of retrospective data, identifying areas for improvement, and its redesign. The dependent variable was the time of patient administrative discharge. The sample was classified as pre-intervention, inter-intervention, and post-intervention, depending on the time point of the study.

RESULTS

The final sample included 14,788 patients after applying the inclusion and exclusion criteria. The mean discharge release time decreased significantly by 50 min between pre-intervention and post-intervention periods. The release time in patients with planned discharge was one hour and 25 min less than in patients with unplanned discharge.

CONCLUSIONS

Process redesign is a useful strategy to improve the process of hospital discharge. Besides planning the discharge, it is shown that the patient leaving the hospital before 12 midday is a key factor.

Interprofessional Communication Patterns During Patient Discharges: A Social Network Analysis

BACKGROUND

Optimal care delivery requires timely, efficient, and accurate communication among numerous providers and their patients, especially during hospital discharge. Little is known about communication patterns during this process.

OBJECTIVE

Our aim was to assess the frequency and patterns of communication between patients and providers during patient discharges from a hospital-based medicine unit.

DESIGN AND APPROACH

On the day of the patient's discharge, the patient and all healthcare providers involved in the discharge were interviewed using structured questions related to information exchange during the discharge process. Each interview identified the frequency and method of communication between participants, including synchronous (e.g., face-to-face) and asynchronous (e.g., through electronic medical record) routes. Communication patterns were visually diagramed using social network analysis.

PARTICIPANTS

Forty-six patients were screened for inclusion in the network analysis. Of those, seven patients who were fully oriented and able to complete an interview and all providers who participated in their care during the discharge were selected for inclusion in the analysis. In all, 72 healthcare professionals contributing to the discharge process were interviewed, including physicians, nurses, therapists, pharmacists, care coordinators, social workers, and nutritionists.

KEY RESULTS

Patients' mean age was 63, length-of-stay was 7.8 days, and most (86 %) were discharged to home. On average, 11 roles were involved with each discharge. The majority of communication was synchronous (562 events vs. 469 asynchronous events, p = 0.004). Most communication events occurred between the primary nurse and patient and the care coordinator and primary nurse (mean 3.9 and 2.3 events/discharge, respectively). Participants identified intern physicians as most important in the discharge process, followed by primary nurses and care coordinators.

CONCLUSIONS

In patients being discharged from the medicine service, communication was more frequently synchronous, and occurred between intern physicians, primary nurses, and patients. Potential improvements in coordinating patients' discharges are possible by reorganizing systems to optimize efficient communication.

Identifying hospitalized pediatric patients for early discharge planning: a feasibility study

A screening tool utilized by nurses at a critical point in the discharge planning process has the potential to improve caregiver decisions and enhance communication. The Early Screen for Discharge Planning-Child version (ESDP-C) identifies pediatric patients early in their hospital stay who will benefit from early engagement of a discharge planner. This study used a quasi-experimental, non-equivalent comparison group design to evaluate the impact of the ESDP-C on important outcomes related to discharge planning. Findings from the study provide preliminary evidence that the integration of the ESDP-C into the pediatric discharge planning process may be clinically useful.

Developing and testing a discharge planning decision support tool for hospitalized pediatric patients

PURPOSE

To develop and test a decision support tool that identifies patients who would benefit from early consult with discharge planners.

DESIGN AND METHODS

A predictive, correlational design was used with parents/guardians of children (1 month to 18 years; N = 197). Data were collected by interviews and record reviews. Expert consensus determined referral to discharge planning.

RESULTS

Mean age was 8.7 years; mean length of stay was 7.5 days. Forty percent (n = 79) were identified for early referral. The variable "substantial post-acute care needs" had the strongest association with expert consensus (internally validated AUC = 0.79).

PRACTICE IMPLICATIONS

Findings from this study provide preliminary evidence for a decision support tool to improve the discharge planning process by reducing individual decision-making variability through systematic matching of patient needs to service delivery.

Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital

OBJECTIVE

To validate patient and nurse short forms for discharge readiness assessment and their associations with 30-day readmissions and emergency department (ED) visits.

DATA SOURCES/STUDY SETTING

A total of 254 adult medical-surgical patients and their discharging nurses from an Eastern US tertiary hospital between May and November, 2011.

STUDY DESIGN

Prospective longitudinal design, multinomial logistic regression analysis.

DATA COLLECTION/EXTRACTION METHODS

Nurses and patients independently completed an eight-item Readiness for Hospital Discharge Scale on the day of discharge. Patient characteristics, readmissions, and ED visits were electronically abstracted.

PRINCIPAL FINDINGS

Nurse assessment of low discharge readiness was associated with a six- to nine-fold increase in readmission risk. Patient self-assessment was not associated with readmission; neither was associated with ED visits.

CONCLUSIONS

Nurse discharge readiness assessment should be added to existing strategies for identifying readmission risk.

Targeting hospitalised patients for early discharge planning intervention

AIMS AND OBJECTIVES

The purpose of the study was to describe the ability of an evidence-based discharge planning (DP) decision support tool to identify and prioritise patients appropriate for early DP intervention. Specifically, we aimed to determine whether patients with a high Early Screen for Discharge Planning (ESDP) score report more problems and continuing care needs in the first few weeks after discharge than patients with low ESDP scores.

BACKGROUND

Improved methods are needed to efficiently and accurately identify hospitalised patients at risk of complex discharge plans.

DESIGN

A descriptive cross-sectional study was designed using a quality health outcomes framework.

METHODS

The ESDP was administered to 260 adults hospitalised in an academic health centre who returned home after discharge. Problems and continuing care needs were self-reported on the Problems After Discharge Questionnaire - English Version, mailed 6-10 days after discharge.

RESULTS

Patients with high ESDP scores reported significantly more problems [mean, 16·3 (standard deviation ±8·7)] than those with low scores [12·2 (±8·4)]. Within the Problems After Discharge Questionnaire subscales, patients with high ESDP scores reported significantly more problems with personal care, household activities, mobility and physical difficulties than patients with low screen scores. Significantly more of the patients with a high ESDP score received consults to a Discharge Planner and referrals for postacute services than patients with low screen scores.

CONCLUSION

The ESDP is effective as a decision support tool in identifying patients to prioritise for early DP intervention.

RELEVANCE TO CLINICAL PRACTICE

Use of an evidence-based DP decision support tool minimises biases inherent in decision-making, promotes efficient use of hospital DP resources, and improves the opportunity for patients to access community resources they need to promote successful recovery after hospitalisation.

Care transitions: integrating transition theory and complexity science concepts

Care transitions, defined as hospital discharge or movement from one health care setting to another, are currently a major concern of health care providers and policy makers. Extensive empirical research has been conducted on care transitions, but the theoretical foundations are rarely made explicit. We propose that integrating concepts on complex adaptive systems from complexity science with classic theory on transitions in nursing provides a powerful new lens through which to study care transitions and improve transition outcomes. We summarize concepts from both theoretical approaches, propose an expanded model of transitions, and apply the model to the transition from hospital to home.