Early discharge planning for elderly patients in acute hospitals--an intervention study

Strategies for utilisation management of hospital services: a systematic review of interventions

Background

To achieve efficiency and high quality in health systems, the appropriate use of hospital services is essential. We identified the initiatives intended to manage adult hospital services and reduce unnecessary hospital use among the general adult population.

Methods

We systematically reviewed studies published in English using five databases (PubMed, ProQuest, Scopus, Web of Science, and MEDLINE via Ovid). We only included studies that evaluated interventions aiming to reduce the use of hospital services or emergency department, frequency of hospital admissions, length of hospital stay, or the use of diagnostic tests in a general adult population. Studies reporting no relevant outcomes or focusing on a specific patient population or children were excluded.

Results

In total, 64 articles were included in the systematic review. Nine utilisation management methods were identified: care plan, case management, care coordination, utilisation review, clinical information system, physician profiling, consultation, education, and discharge planning. Primary case management was shown to effectively reduce emergency department use. Care coordination reduced 30-day post-discharge hospital readmission or emergency department visit rates. The pre-admission review program decreased elective admissions. The physician profiling, concurrent review, and discharge planning effectively reduced the length of hospital stay. Twenty three studies that evaluated costs, reported cost savings in the hospitals.

Conclusions

Utilisation management interventions can decrease hospital use by improving the use of community-based health services and improving the quality of care by providing appropriate care at the right time and at the right level of care.

Identifying features associated with higher-quality hospital care and shorter length of admission for people with dementia: a mixed-methods study

Background

Concerns have repeatedly been expressed about the quality of inpatient care that people with dementia receive. Policies and practices have been introduced that aim to improve this, but their impact is unclear.

Aims

To identify which aspects of the organisation and delivery of acute inpatient services for people with dementia are associated with higher-quality care and shorter length of stay.

Design

Mixed-methods study combining a secondary analysis of data from the third National Audit of Dementia (2016/17) and a nested qualitative exploration of the context, mechanism and outcomes of acute care for people with dementia.

Setting

Quantitative data from 200 general hospitals in England and Wales and qualitative data from six general hospitals in England that were purposively selected based on their performance in the audit.

Participants

Quantitative data from clinical records of 10,106 people with dementia who had an admission to hospital lasting ≥ 72 hours and 4688 carers who took part in a cross-sectional survey of carer experience. Qualitative data from interviews with 56 hospital staff and seven carers of people with dementia.

Main outcome measures

Length of stay, quality of assessment and carer-rated experience.

Results

People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission. This is a challenging task when patients have complex needs, and requires named staff to take responsibility for co-ordinating the discharge and effective systems for escalating concerns when obstacles arise. When trust boards review delayed discharges, they can identify recurring problems and work with local stakeholders to try to resolve them. Carers of people with dementia play an important role in helping to ensure that hospital staff are aware of patient needs. When carers are present on the ward, they can reassure patients and help make sure that they eat and drink well, and adhere to treatment and care plans. Clear communication between staff and family carers can help ensure that they have realistic expectations about what the hospital staff can and cannot provide. Dementia-specific training can promote the delivery of person-centred care when it is made available to a wide range of staff and accompanied by ‘hands-on’ support from senior staff.

Limitations

The quantitative component of this research relied on audit data of variable quality. We relied on carers of people with dementia to explore aspects of service quality, rather than directly interviewing people with dementia.

Conclusions

If effective support is provided by senior managers, appropriately trained staff can work with carers of people with dementia to help ensure that patients receive timely and person-centred treatment, and that the amount of time they spend in hospital is minimised.

Future work

Future research could examine new ways to work with carers to co-produce aspects of inpatient care, and to explore the relationship between ethnicity and quality of care in patients with dementia.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 22. See the NIHR Journals Library website for further project information.

Delayed Hospital Discharges of Older Patients: A Systematic Review on Prevalence and Costs

PURPOSE OF THE STUDY

To determine the prevalence of delayed discharges of elderly inpatients and associated costs.

DESIGN AND METHODS

We searched Medline, Embase, Global Health, CAB Abstracts, Econlit, Web of Knowledge, EBSCO - CINAHL, The Cochrane Library, Health Management Information Consortium, and SCIE - Social Care Online for evidence published between 1990 and 2015 on number of days or proportion of delayed discharges for elderly inpatients in acute hospitals. Descriptive and regression analyses were conducted. Data on proportions of delayed discharges were pooled using a random effects logistic model and the association of relevant factors was assessed. Mean costs of delayed discharge were calculated in USD adjusted for Purchasing Power Parity (PPP).

RESULTS

Of 64 studies included, 52 (81.3%) reported delayed discharges as proportions of total hospital stay and 9 (14.1%) estimated the respective costs for these delays. Proportions of delayed discharges varied widely, from 1.6% to 91.3% with a weighted mean of 22.8%. This variation was also seen in studies from the same country, for example, in the United Kingdom, they ranged between 1.6% and 60.0%. No factor was found to be significantly associated with delays. The mean costs of delayed discharge also varied widely (between 142 and 31,935 USD PPP adjusted), reflecting the variability in mean days of delay per patient.

IMPLICATIONS

Delayed discharges occur in most countries and the associated costs are significant. However, the variability in prevalence of delayed discharges and available data on costs limit our knowledge of the full impact of delayed discharges. A standardization of methods is necessary to allow comparisons to be made, and additional studies are required-preferably by disease area-to determine the postdischarge needs of specific patient groups and the estimated costs of delays.

Supported Discharge Teams for older people in hospital acute care: a randomised controlled trial

Background

Supported Discharge Teams aim to help with the transition from hospital to home, whilst reducing hospital length-of-stay. Despite their obvious attraction, the evidence remains mixed, ranging from strong support for disease-specific interventions to less favourable results for generic services.

Objective

To determine whether older people referred to a Supported Discharge Team have: (i) reduced length-of-stay in hospital; (ii) reduced risk of hospital readmission; and (iii) reduced healthcare costs.

Methods

Randomised controlled trial with follow-up to 6 months; 103 older women and 80 men (n = 183) (mean age 79), in hospital, were randomised to receive either Supported Discharge Team or usual care. Home-based rehabilitation was delivered by trained Health Care Assistants up to four times a day, 7 days a week, under the guidance of registered nurses, allied health and geriatricians for up to 6 weeks.

Results

Participants randomised to the Supported Discharge Team spent less time in hospital during the index admission (mean 15.7 days) in comparison to usual care (mean 21.6 days) (mean difference 5.9: 95% CI 0.6, 11.3 days: P = 0.03) and spent less time in hospital in the 6 months following discharge home. Supported discharge group costs were calculated at mean NZ$10,836 (SD NZ$12,087) compared to NZ$16,943 (SD NZ$22,303) in usual care.

Conclusion

A Supported Discharge Team can provide an effective means of discharging older people home early from hospital and can make a cost-effective contribution to managing increasing demand for hospital beds.

Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge?

BACKGROUND

Poorly-executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization.

OBJECTIVE

To evaluate the cost avoidance associated with implementation of the Care Transitions Intervention (CTI).

DESIGN

A quasi-experimental cohort study using consecutive convenience sampling.

PATIENTS

Fee-for-service Medicare beneficiaries hospitalized from 1 January 2009 to 31 May 2011 in six Rhode Island hospitals.

INTERVENTION

The CTI is a patient-centered coaching intervention to empower individuals to better manage their health. It begins in-hospital and continues for 30 days, including one home visit and one to two phone calls.

MAIN MEASURES

We examined post-discharge total utilization and costs for patients who received coaching (intervention group), who declined or were lost to follow-up (internal control group), and who were eligible, but not approached (external control group), using propensity score matching to control for baseline differences.

KEY RESULTS

Compared to matched internal controls (N = 321), the intervention group had significantly lower utilization in the 6 months after discharge and lower mean total health care costs ($14,729 vs. $18,779, P = 0.03). The cost avoided per patient receiving the intervention was $3,752, compared to internal controls. Results for the external control group were similar. Shifting of costs to other utilization types was not observed.

CONCLUSIONS

This analysis demonstrates that the CTI generates meaningful cost avoidance for at least 6 months post-hospitalization, and also provides useful metrics to evaluate the impact and cost avoidance of hospital readmission reduction programs.

Medical Assessment Units and the older patient: a retrospective case-control study

OBJECTIVE

To evaluate the effect of a Medical Assessment Unit (MAU) on older patients.

METHODS

Retrospective case-control study of patients 65 years and above admitted to the MAU (study group) and the general medical wards (control group) in Bankstown-Lidcombe Hospital from 1 October 2008 to 31 March 2009 with four most common Diagnosis-Related Groups (DRG) ('falls and gait disorder', 'chronic obstructive pulmonary disease (COPD)', 'other major respiratory diseases and 'cellulitis').

MAIN OUTCOME MEASURES

Length of stay (LOS) in Emergency Department (ED) and in the hospital, mortality, readmissions within 1 month, and discharge destination.

RESULTS

Eighty-nine patients were studied; 47 in the MAU group and 42 in the non-MAU group. The MAU cohort was significantly older (84.1 ± 7.9 years v. 80.4 ± 7.8 years, respectively, P=0.03); and had shorter ED LOS (4.9 ± 3.0h v. 6.5 ± 2.8h, P=0.012). Overall hospital LOS did not differ except for patients with 'cellulitis', (5.7 ± 4.9 days for MAU cohort v. 14.8 ± 6.8 days for non-MAU cohort, P=0.022). There was no significant difference in mortality, readmission rate or discharge destination. Conclusions. The MAU can be an effective service model for older patients. More research is required to confirm this and to define the key elements that are essential for its effectiveness.

Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study

Background

Geriatric patients recently discharged from hospital experience increased chance of unplanned readmissions and admission to nursing homes. Several studies have shown that medication-related discrepancies are common. Few studies report unwanted incidents by other factors than medications. In 2002 an ambulatory team (AT) was established within the Department of Geriatrics, St. Olavs University Hospital HF, Trondheim, Norway. The AT monitored the transition of the patients from hospital to home and four weeks after discharge in order to reveal unwanted incidents.

The aim of the present study was to describe unwanted incidents registered by the AT among patients discharged from a geriatric evaluation and management unit (GEMU) by character, frequency and stage in the transitional process. Only unwanted incidents with a severity making contact with the primary health care (PHC) necessary were registered.

Methods

A prospective observational study with patients treated in the GEMU and followed by the AT was performed. Current practice included comprehensive geriatric assessment and management including discharge planning in the GEMU and collaboration with the primary health care on appointments on assistance to be provided after discharge from hospital. Unwanted incidents severe enough to induce contact with the primary health care were registered during the transitional phase and after discharge.

Results

118 patients (65% female), with mean age 83.2 ± 6.4 years participated. Median Barthel Index at discharge was 18 (interquartile range 16-19) and median Mini Mental Status Examination 24 (interquartile range 21-26). A total of 146 unwanted incidents were registered in 70 (59%) of the patients. Most frequent were unwanted incidents related to drug prescription regime (32%), exchange of information in and between the GEMU and the primary health care (25%) and service or help provided from the PHC (17%).

Conclusions

Despite a seemingly well-organised system for transition of patients from the GEMU to their homes, one or more unwanted incidents occurred in most patients during discharge or four weeks post discharge. The study has revealed areas of importance for improving transitional care of geriatric patients.

Improving post-stroke health outcomes: can facilitated care help?

OBJECTIVES

The objectives of this study were (1) identifying the patterns of post-stroke care, (2) determining the care-provider and patient characteristics associated with optimal management of post-stroke care and (3) estimating the potential influence of various facilitated care policies on outcomes.

METHODOLOGY

The 3946 subjects included in the study were admitted to one of Quebec's acute-care hospitals with confirmed diagnosis of stroke and subsequently discharged to their home. The records related to fee-for-service billings of this sample were obtained for the 3 months following discharge and used to define the care-provider path for each stroke survivor. These paths were analyzed and the potential impact of various facilitated care interventions was estimated via a Markov model.

RESULTS

The rate of mortality for this sample was 3.2% during the first 3 months after discharge. For the patients who were re-hospitalized, however, the mortality rates were up to 10.3% depending on the care-provider visited prior to re-hospitalization. Our analyses indicate that by avoiding such critical sub-paths via facilitated care, it is possible to achieve improvements in health outcomes as well as cost.

DISCUSSION

There is a window of opportunity for improving community-based post-stroke care. Facilitated care policies concerning planned visits upon discharge from hospital or following ER visits can improve the outcomes.

Discharge planning from hospital to home for elderly patients: a meta-analysis

In the present healthcare environment, budget cuts, staff shortages, and resource limitations are grave concerns. The elderly in particular consume a considerable proportion of hospital resources. Thus, the discharge planner's role, particularly with respect to elderly patients, is extremely important. In this systematic review recent (within the last 10 years) randomized, controlled or quasi-experimental trials of discharge planning (DP) from hospital to home of patients age 65 years or older were examined. The most important finding was the paucity of investigations by social work professionals. A second important finding was the lack of appropriate reporting of methods and results. Where data were provided, an effect size was computed for statistically significant results (overall mean d = 0.51, SD 0.35). Large effects were noted for patient satisfaction, while moderate effects were evident for patients' quality of life and readmission rates. The integration and evaluation of current knowledge in this field may inform further research and may lead to the advancement of clinical practice and new policy development, with the ultimate goal of improving the quality of patient care and the quality of patient outcomes. The implications for social work clinicians and researchers are discussed.

Evidence‐based re‐engineering: re‐engineering the evidence

PURPOSE

Business process redesign (BPR) is used to implement organizational transformations towards more customer-focused and cost-effective care. Ideally, these innovations should be carefully described and evaluated so that "best practices" can be re-applied. To investigate this, available evidence was collected on patient care redesign projects.

DESIGN/METHODOLOGY/APPROACH

The Ebsco Business Source Premier, Embase and Medline databases were searched. Studies on innovations related to re-engineering patient care that used before-after design as minimum prerequisites were selected. General characteristics, logistic parameters and other outcome measures to determine the objectives and results and interventions used were looked at.

FINDINGS

A total of 86 studies that conformed to the criteria were found: a minority mentioned measurable parameters in their objectives. In the majority of studies, multiple interventions were combined within single studies, making it impossible to compare the effects of individual interventions. Only three randomized controlled trials were found. Furthermore, inconsistencies were noted between the study objectives and the reported results. Many more issues were reported in the results than were mentioned in the study aims. It would appear that publications were hard to find owing to a lack of specific MeSH headings. Nearly 7,500 abstracts were scanned and from these it was concluded that clear and univocal research methods, terms and reporting guidelines are advisable and must be developed in order to learn and benefit from BPR innovations in health care organizations.

ORIGINALITY/VALUE

This appears to be the first time available evidence about redesign projects in hospitals has been systematically collected and assessed.

Acute geriatric intervention increases the number of patients able to live at home. A prospective randomized study

BACKGROUND AND AIMS

In a previous publication, we showed that treatment of acutely sick, frail elderly patients in a Geriatric Evaluation and Management Unit (GEMU) reduced mortality considerably when compared with the general Medical Wards (MW). The aim of this presentation was to study the impact of treatment in a GEMU on health care utilization.

METHODS

Acutely sick, frail patients, 75 years or older, who had been admitted as emergencies to the Department of Internal Medicine were randomized either to treatment in the GEMU (n=127) or to continued treatment in the MW (n=127). While usual treatment was given in the MW, the GEMU emphasized interdisciplinary and comprehensive assessment of all relevant disorders, early mobilization/rehabilitation, and discharge planning. After discharge from hospital, no specific follow-up was offered to any of the groups.

RESULTS

Of all subjects, 101 (80%) GEMU and 79 (64%) MW patients were still living in their own homes at three months (p=0.005); at six months the number was 91 (72%) and 74 (60%) (p=0.04) respectively. Median length of index stay was 19 days in the GEMU and 13 days in the MW group (p<0.001). After the initial stay, there were no statistically significant differences in admissions to or time spent in institutions.

CONCLUSIONS

The results indicate the overall positive treatment effect of acutely sick, frail elderly in a GEMU, i.e. patients treated in the GEMU had increased possibilities of living in their own homes, an effect that was mainly related to considerably reduced mortality in the GEMU group.

Discharge of frail older people from acute hospitals across Europe

Over the last few years the number of elderly patients in acute hospitals throughout Europe has risen dramatically. The pressure on hospital beds leads to earlier discharge and the task of sending patients home from hospitals is becoming more complex. The provision of health and social services is organized in different ways all over Europe. Therefore, it would be of interest to know more about how different kinds of systems support the professional carers in their effort to satisfy the needs which older people and their significant others experience in the discharge process. A pilot study was set up mainly to provide information on what kinds of problems are inherent in a multicentre, interprofessional research project involving a large number of countries. The findings serve as an important knowledge base in a future project. Experiences from the pilot study and the benefits of it are presented.

Length of hospital stay and discharge delays in stroke patients

BACKGROUND AND PURPOSE

In The Netherlands, many stroke patients stay in the hospital for some time merely waiting for discharge placement. This indicates an inefficient use of hospital resources, as well as a possible deficiency in the quality of care, because hospitals are not adequately equipped to care for these patients. In this study, we tried to quantify this "waiting problem."

METHODS

Six hospitals and 29 neurologists participated in this prospective study. The neurologists were asked during weekly interviews to specify for 154 patients the reason for retention in the hospital on a day-to-day basis. The reasons were noted on a list specified by the authors in advance.

RESULTS

The mean length of hospital stay was 28 days. On average, there were "hard" medical reasons for 15 days (54%) and "soft" medical reasons for 3 days (10%), whereas the remaining 10 days (36%) were explained by nonmedical reasons (most frequently, waiting for placement in a nursing home).

CONCLUSIONS

The length of hospital stay for stroke patients in The Netherlands can be reduced considerably without compromising the quality of care. This might be realized by increasing the capacity of long-term care facilities, improving the efficiency of the discharge procedures, or creating "stroke services."