Government Policy into Action: Good Discharge of Patients Leaving General Hospitals, Part 1

This article summarises the Department of Health Circular (89)5 which requires health authorities to ensure good arrangements for patients' discharge from hospital. It reviews the literature on this topic and compares what has been said with what has been meant when professionals have written about their participation in the process of discharge. The second article deals with models of policy implementation by which the policy process can be analysed in order to inform implementation methods. It describes how implementation has been tackled so far in one health district.

Occupational Therapy Home Visits: A Satisfactory Service?

A questionnaire was directed towards establishing whether therapist, patients and carers had similar concerns at the point of discharge from a small community hospital, and whether or not these concerns were addressed effectively by the predischarge occupational therapy home visit. On the whole, the visits were found to be comprehensive and very helpful to all participants. There was, however, a significant difference between the three groups in how helpful they had found the discussions on social isolation. There were further differences in the way the three groups responded to advice on financial benefits and community services and in the intended reassuring nature of the visit. Results point to a need for the therapists to re-examine the way in which these particular topics are addressed and the priority they are given within the visit. There is also a need to re-examine the service offered to carers.

Home Assessment Visits within the Acute Setting: a Discussion and Literature Review

The emphasis on the effective and efficient use of finite resources within acute hospitals has led to close attention being paid to the length of patients' hospital stay and the assessment of risk in facilitating timely hospital discharge. Occupational therapy home assessment visits are valued by the multidisciplinary team as a means of assessing a patient's level of function and environmental risk to ensure safe discharge from hospital.

Occupational therapists' education and training and experience mean that they are well placed to predict levels of function postdischarge and to anticipate any problems that may occur in activities of daily living. However, for patients the home assessment visit can be a stressful and bewildering experience. The short-term focus on equipment provision combined with limited postdischarge intervention may not meet patient and carer expectations or concerns with longer-term issues.

Although there is a body of evidence to support this intervention, the requirement for evidence-based practice means that there is a need for additional research around the areas of optimal timing, selection of patient groups, therapist's rationale, patient and carer perspectives and any effect that home assessments may have on readmission rates. This paper discusses the literature in relation to the practice of home assessment visits from the acute setting.

Occupational Therapy Predischarge Home Visits: A Study from a Community Hospital

The characteristics of 79 patients in a community hospital having an occupational therapy home visit during a period of one year were monitored. The processes of the home visit were examined and, in particular, the relationships of diagnosis and overall measures of levels of functioning – the Physical Self-Maintenance (PSM) and Instrumental Activities of Daily Living (IADL) scales – with the recommendations of the occupational therapists were analysed.

The 79 patients had a mean age of 78.5 years; 27 (34.2%) were male and 58 (73.4%) lived alone. The mean time spent in the home by the occupational therapist was 49 minutes and the mean time for the whole visit including travelling time was 108.4 minutes. Only one patient (1.3%) was completely independent in all six PSM categories and no patient was completely independent in all eight IADL items. Seventy-two (91.6%) patients were eventually discharged to a non-institutional setting, mainly the patient's own home.

Current diagnosis, except for cerebrovascular disease, was not significantly related to higher overall dependency, recommended equipment or carer visit frequency. Higher overall dependency showed significant relationships with recommended carer frequency and time spent assessing the patient in the home, but not consistently with recommended equipment or home adaptations. When specific categories of equipment were considered, for example that for use in the kitchen, overall low dependency was significantly related to the recommendation for this type of equipment.

The study confirms the need for assessments beyond those of diagnosis alone in rehabilitation. Overall measures of levels of functioning, although useful in measuring outcomes, are of less certain value for assessment. Specific subcategories of dependency scales are probably of more value than overall scores for occupational therapy assessment.

Designing the Home Falls and Accidents Screening Tool (HOME FAST): Selecting the Items

The Home Falls and Accidents Screening Tool (HOME FAST) was developed as a screening instrument for use in a community preventive care trial for older people. This paper describes the first stage of the development of this screening tool. The objectives of the study were (i) to review existing home safety measures, (ii) to field test an instrument containing a pool of home safety items with the goal of identifying those hazards associated with falls in the home and (iii) to select the items for inclusion in a 25-item tool using an expert panel.

The field testing took place in a rural area of Australia, where the pooled checklist was used to evaluate hazards within the homes of 83 older people. No individual hazards were associated with the risk of falls at home and, although participants who had experienced falls had a higher mean number of home hazards (mean = 13.7, SD 8.2), the differences between fallers and non-fallers was not significant. Items relevant to a rural population were indicated through field testing. Further psychometric testing of the HOME FAST and a meaningful method of scoring the checklist are now warranted.

To Bath or Not to Bath? A Joint Initiative to Resolve the Problem of Increasing Demand for Bath Assessments, Part 2

The second article examines the process and findings following the operation of the bath clinic as a means of reducing and rationalising bath assessments and decreasing the caseload of the social services occupational therapists. It outlines the way that the clinic has developed, examines the monitoring of the clinic and the alterations made to improve its running and success, and provides an evaluation following continued data collection.

A survey of predischarge occupational therapy home assessment visits for stroke patients

Home assessment visits are a part of inpatient stroke rehabilitation programmes, but surprisingly little has been written about how often they are used or what they achieve. This study describes the use of home visits in 327 patients in a study of stroke rehabilitation after discharge from hospital.

Home visits were noted in 149 (50%). A median of five problems were identified, most commonly involving mobility inside the property and the height of furniture hampering transfers. A median of four solutions were recorded, most commonly the provision of aids and equipment. Representatives of the community social and nursing services were present in a minority of visits. An occupational therapist (OT) from the Social Services was present in half the home visits in addition to the hospital OT.

The study concludes that several important problems are identified on home visits and that simple solutions can be found in most cases. Social and health services, in Nottingham at least, should develop more rational working practices for home visits, so that liaison between hospital and community services is improved and duplication of work is avoided.

A Prospective Community-Based Study of Falls among Older People in Australia: Frequency, Circumstances, and Consequences

Falls among the population of older people are a major international public health concern. Few prospective studies have been conducted in Australia with a healthy, rural and urban community sample that measure a broad range of health-related potential risk factors for falls. This study aims to identify the nature and circumstances of falls experienced by people aged 70 years and older, and explores any health and environmental variables associated with falls over a 6-month period. A total of 264 participants kept calendars and recorded information about falls. Health status measures were taken prior to the study period. Falls occurred mainly during mobility and housework activities causing a wide range of minor but notable injuries, and were associated with psychosocial factors as well as medical risk factors. The need for occupational therapists to develop specific programs for healthy older people living in the community is identified, as well as the need for cross-national falls research.

Measurement properties of the occupational therapy discharge needs screen

BACKGROUND

Pre-discharge home assessments are integral to discharge planning; however, there is no screening tool identifying clients with complex needs.

PURPOSE

To determine the inter- and intrarater reliability and predictive and concurrent validity of the Occupational Therapy Discharge Needs Screen (OTDNS), a screening tool that identifies clients with more complex discharge needs.

METHODS

The OTDNS Functional Independence Measure (FIM) and Functional Autonomy Measurement System (SMAF) were administered to 89 participants.

FINDINGS

Intrarater reliability was ICC = 0.93 (95% CI 0.90 - 0.96) (n = 89). Interrater reliability was ICC = 0.53 (95% CI 0.27- 0.70) (n = 89) with the initial OTDNS instructions, and ICC = 0.91 (95% CI 0.62 - 0.96) (n = 10) with revised OTDNS instructions. The OTDNS had an inverse relationship with the FIM (r = -0.51; p < 0.001) and a positive relationship with the SMAF (r = 0.64; p < 0.001). A score of > 7/28 had a sensitivity = 75% and specificity = 40% when predicting occupational therapy home assessment post-discharge.

IMPLICATIONS

The OTDNS has potential to contribute to continuity and efficiency of the discharge-planning process.

Older Adults' Experiences of Occupational Therapy Predischarge Home Visits: A Systematic Thematic Synthesis of Qualitative Research

Background:

Occupational therapists in many countries routinely perform predischarge home visits. Although there have been repeated calls to ascertain whether predischarge home visits are clinically and cost effective, there has been a tendency to neglect users' perceptions and experiences of this intervention.

Objective:

The objective was to conduct a systematic thematic synthesis of older adults' perceptions and experiences of predischarge home visits.

Method:

The search strategy was an electronic database search. Conference proceedings were hand searched and universities and occupational therapy professional bodies within Europe, Australia and North America were contacted.

Results:

Forty-four studies were initially identified, of which 13 studies (7 published, 6 unpublished) were selected for detailed screening. Only three qualitative studies met the inclusion criteria and, from this synthesis, two main themes emerged from the data. The first theme was older adults' perceptions of home visits and the second theme was acceptance of occupational therapy.

Conclusion:

Only a limited body of research has been conducted. This is surprising given the number of predischarge home visits that are performed. This thematic synthesis of qualitative research has highlighted that insufficient attention has been paid to older adults' perceptions of predischarge home visits.

Occupational Therapy Home Assessments: More than Just a Visit? An Audit of Occupational Therapy Practice in Oncology and Palliative Care

Occupational therapists at a specialist cancer centre found home assessments to be the most time-consuming intervention. To evaluate the breakdown of time and total time use for this intervention, 15 occupational therapists working in the area of oncology and palliative care participated in an audit. A total of 107 home assessments was audited. The results indicated that the total time for an average home assessment in the audit ranged between 3.31 hours and 5.59 hours. They also highlighted that the time spent in preparation and follow-up was similar to the time spent in travel and the visit itself.

Pre-discharge home visits with older people: time to review practice

The present review paper uses the available evidence to make a case for a reconsideration of the practice of undertaking pre-discharge home visits with frail older people as part of decisions regarding a return home. This practice is embedded into the routine activity of acute medical wards for older people and occupies a large proportion of the time of hospital employed therapy staff, with consequent financial and resource implications. Assessments are often conducted to provide information on safe discharge rather than being located in the interests of the older person and their carer. The introduction of a new range of services bridging hospital and home raises the need for an urgent, critical appraisal of this practice.

Too many pre-discharge home assessment visits for older patients? A postal questionnaire survey

OBJECTIVE

To investigate current practice of pre-discharge home assessment visits for older patients.

DESIGN

Postal questionnaire survey.

SETTING

NHS Trust hospitals in the United Kingdom.

SUBJECTS

Occupational therapy departments in 265 NHS Trust hospitals which admit acutely ill older patients.

MAIN OUTCOME MEASURES

The number of pre-discharge home visits done, who went, and therapy time spent on home visits.

RESULTS

Of 265 NHS Trusts contacted, 239 (90%) replied. Of 238 units, 155 (65%) do between 11 and 40 visits per month, with 25 (11%) doing more than 60. The equivalent of one day per week or more is spent doing home visits by Senior I occupational therapists in 107 (45%) units and by Senior II staff in 126 (53%) units. Carers or relatives, unqualified occupational therapists, social workers and home care managers accompany the patient and occupational therapist on most home visits.

CONCLUSION

Therapy perception is that pre-discharge home assessment visits are increasing in number, complexity and involvement of professional time despite little evidence for their effectiveness. Controlled trials are required to assess which patients are likely to benefit.

The effectiveness of predischarge home assessment visits: a systematic review

OBJECTIVE

To evaluate the effectiveness of predischarge home assessment visits for elderly patients.

DESIGN

Systematic review.

METHODS

A computer-aided search was conducted using the databases of Medline and Cinahl. Any studies investigating predischarge home assessment visits were included in the analysis.

RESULTS

No randomized controlled trials were found. Only five studies (two retrospective surveys, three observational surveys) were identified. In four of these, a possible benefit for home visiting was suggested.

CONCLUSIONS

Little evidence exists for the effectiveness of predischarge home assessment visits. Further research is needed to establish their value.