Sick people, particularly those with serious conditions, greatly prefer the company of their friends and family to residence in a hospital or nursing home.
In modern medicine, appropriate discharge planning for elderly patients must not be forgotten when considering hospital organization, for several important reasons:
the high prevalence of disability in individuals >65 years of age, i.e., 25% in males and 34% in females (Maggi et al. 2004)
the high risk of developing new disabilities following acute medical illness and hospitalization, with a prevalence of disability of over 50% in subjects more than 70 years of age discharged from hospital (Sager et al. 1996); the consequence is that the most complex and oldest patients are rarely discharged after full psychological-physical recovery and still need care and assistance in another social/health setting or at home
the economic sustainability of the hospital system; indeed, it is essential to limit the hospital stay to the time necessary to take care of the present disease (but no less), and to reduce inappropriate readmissions of elderly frail patients discharged without adequate planning
the need for continuity of care, both within the hospital and between hospital and the destination setting (home, nursing home, etc.). It has been calculated that about 40% of hospitalized patients over 85 years of age are discharged to a skilled nursing facility (Wier et al. 2010); therefore, the appropriateness of the setting of the care has to be guaranteed in order to avoid frequent and unsuitable admissions to hospital.
For these reasons, the development of a discharge plan (DP) is a clinical/organizational method which, by means of a multidimensional analysis of the patient’s needs, generates a discharge project defining the right setting and the type of interventions useful for achieving the maximum health target for the individual patient.
Discharge Organization in Practice
In the last few years, evidence has emerged about the existence of a period of time after hospital discharge for surgery, characterized by increased chance of illness, often leading to readmission and a negative outcome in elderly patients. This situation has been known for many years in the field of geriatric medicine (Landefeld et al. 1995), and is subject of particular attention in Acute Care for Elders (ACE) units (Barnes 2012). It has been recently been termed post-hospital syndrome (Krumholz 2013)and is commonly characterized by:
high prevalence; about on-fifth of patients discharged from hospital are readmitted within 30 days (Jencks et al. 2009) because of a clinical syndrome different from the primary cause of hospitalization (infections, heart failure, COPD, GI disorders, delirium, metabolic diseases, traumas, etc.)
transient and generalized clinical vulnerability (starting during hospitalization, but worsening after discharge) with variable duration, depending on the overall quality of hospital care and other factors, such as advanced age, comorbidities, general health condition before admission, cognitive and functional status, and social/care situation at home
a close relationship with different types of stressors (physical, ambient, psycho-emotional) during the stay in hospital, including sleep deprivation, protein-energy malnutrition, lack of movement, devices (e.g. Foley), pain, discomfort and fear of hospital admission;
the risk of developing (through weight reduction, hypercatabolism, immune-suppression, hypercoagulation, and decreased blood hemoglobin and albumin levels) problems in surgical scar healing with risk of infections and bedsores
deconditioning to muscle work, with worsening functional performance, hypomobility, reduction in strength and coordination, and increased risk for falls and fractures.
In order to limit the risk of developing such a syndrome, it is possible to intervene:
from a clinical point of view: by preventing physical, environmental and psychological stressors during hospitalization:
optimizing pharmacological therapy (especially avoiding medications that can alter cognition) and correctly reconciling medication at hospital discharge
minimizing pain, sleep disturbances, social isolation and delirium
reducing, whenever possible, the use of devices
paying serious attention to nutrition and hypovolemia
paying serious attention to maintaining the functional status (mobilization)
from an organizational point of view:
early identification of patients at high risk of negative effects of discharge, and reserving for them, based on the risk level:
– pathways of transitional care before discharge, for a safe return to home
We could say that discharge planning starts at the time of admission to hospital. Indeed, from obtaining a clinical history and interviewing the elderly patient and her/his caregivers, some elements suggesting the possible need for specific interventions or itineraries for continuity of care after discharge might emerge. Conventionally, we could assert that within 72 hours of admission to hospital the staff should have sufficient data on the patient’s condition (clinical, healthcare, functional, psychological and cognitive, social, familial) to plan an “approximate” pathway after hospital discharge. Of course, a DP could be progressively re-elaborated, depending on the evolution of the acute phase of the disease and/or on the progressive stabilization of the health condition of the patient. Immediately after admission, both patient and caregiver should be engaged through continuous and appropriate information about the care plan and sharing in discharge planning.
The management of a DP requires two main elements: standardized organization and a personalized approach. In order to obtain an appropriate DP, the hospital organization must provide for a network of structured pathways (between hospital and local/residential structures) able to take responsibility for the problems of elderly patients. These organizational models (the availability of services and types of facilities vary significantly across geographic areas) should include:
The DP process is typically:
Multidimensional: the definition of the care plan for an elderly patient must be based on the evaluation of his/her most significant areas of concern (clinical, healthcare, cognitive, psychological, social)
Multiprofessional: in a modern hospital system the nursing staff should have sufficient competence to identify the social and care needs of the elderly patient; this should be obtained:
in an informal way, based on knowledge of the functional status directly evaluated during hospitalization
in a structured way, by specific rating scales or questionnaires for the assessment of needs, which help the staff to make an “objective” evaluation about the possibility of discharging the patient to their home or another posthospital setting
Multidisciplinary: a DP is an essential part of the Comprehensive Geriatric Assessment (see Chapter 2), which is the basis of geriatric methodology; thus, it is evident that in all the different hospital settings the participation of a specialist geriatrician (comanagement of the elderly patient or consultation) makes available his/her ability, experience and competence in the overall evaluation of patients and their needs (Ellis et al. 2011).
For these reasons, there are some parameters that specifically characterize the efficacy of a DP (Carrol and Dowling 2007):
the ability to communicate among the staff involved in the development of the DP, within both the hospital and the transitional care through information/computer channels or simply through the writing of a showing the individual care plan for each older patient
the collaboration between medical and assistance staff
the involvement of the patient and her/his family in the implementation of the DP
the ability to coordinate and integrate the DP activities, utilizing positions with a specific responsibility for this function (case/team manager for the DP).
Aspects to Evaluate
The need for long-term institutionalization after acute hospital admission is common among older patients. A recent systematic review of 23 studies investigating predictors of discharge to long-term institutional care following acute hospitalization confirmed that, despite being provided by scarce predictive value due to low quality and high heterogeneity of studies, advanced age, dementia, female sex and functional dependency are associated with a need for post hospital institutionalization (Harrison et al. 2017). However, identifying individuals at risk early in their admission is not easy.
Some specific aspects of the older patient provide strategic information for the definition of the best DP for each patient. The most common and basic critical elements are:
social care conditions before admission; the possible lack or unavailability of relatives able to take care of the patient at home (for economical and/or organizational reasons; Jacob and Poletick 2008);
cognitive function before admission to hospital
clinical complexity of the patient and the need for treatment
assessment, during hospitalization, of the presence of possible stressors suggesting potential for post-hospital syndrome
functional status at the time of discharge, and especially its relationship to function before admission
indication for prolonged and complex therapeutic programs
indication for structured rehabilitation/reactivation plans, especially after orthopedic, cancer or cardiac surgery.
How to Manage the DP
The most original experiences reported in literature suggest that sufficiently experienced nursing personnel may oversee, through the creation of ad hoc organizational positions (nurse care manager, DP coordinator, nurse case manager), the implementation of the DP (Hunter et al. 2013). The employment of these positions makes it necessary for the implementation of hospital organizations which formalize this role and its tasks by using codified procedures and a structured interface with the post-hospital care settings. The simple transmission of a complete written documentation between the different settings seem to be less effective for the quality of the DP process.
Moreover, it would be desirable for monitoring of the DP to be realized by:
pro-active telephone/computer contacts (predischarge interventions), with relatives or caregivers, by the operative unit discharging the elderly patient or, when present, by discharge planners (care/case manager or the team responsible for planning the DP).
after discharge, through structured contact (telephone, fax, e-mail) between the posthospital setting and those responsible for discharge (post-discharge interventions).
The Content of the DP
Basically, four steps for concrete realization of the DP can be identified:
multidimensional evaluation of the elderly patient, the preliminary step in identifying cases requiring a “safe pathway” after discharge
identification of the most suitable extra-home care setting; correct selection of a setting to which to submit information on the clinical and care characteristics of the patient accompanied by a personalized care plan (the right patient in the right setting).
preparation of the home context and of the informal domestic familial/care resources for reception of the patient after discharge, intended as education and training as to the appropriate care for the individual patient (i.e., use of devices and medical instruments, the method of drug administration, simple and complex dressings, etc.)
arrangement at home of all the care actions to guarantee the real prospect of continuing care for the patient (recommendations about mobilization and nutrition, prescription and practical indications about the use of devices and medical aids, clear instructions about wound dressing and postdischarge surgical follow-up, information about fall prevention, etc.), as well as the elaboration of a suitable plan of pharmacological therapy.
The variety of clinical and care elements that need to be analyzed in order to plan the discharge make it necessary to apply reliable tools, validated for the analysis of the overall needs of elderly, frail individuals. In this context several scales are available, the most tested of which is the Blaylock Risk Assessment Screening Score (BRASS) (Blaylock and Cason 1992).
The BRASS index (Blaylock and Cason 1992), developed for subjects >65 years of age by experts in geriatric problems, analyzes some important factors for the care needs of patients admitted to hospital, including age, caregiver availability, functional state, cognitive function, presence of behavioral disturbances, motor competence, sensorial deficits, admission to the emergency room and/or to hospital during the three previous months, number of active medical problems and current therapy (number of drugs). The index should be evaluated at the time of admission to the ward; it is easy to complete and needs minimal staff training. This index identifies three classes of risk for discharge intervention need, with increasing complexity (Figure 43.1).
The BRASS scale has been widely utilized in different clinical studies, especially in the medical and orthopedic fields. BRASS has shown high predictive value for the duration of hospital admission, both when used singly or together with other parameters, such as age, ASA score, body mass index and type of surgical intervention (Cunic et al. 2014, Mistiaen et al. 1999, Chaboyer et al. 2002), in comparison with which it already has higher predictive power regarding discharge problems.
Currently, randomized clinical trials show heterogeneous results as regards the principal outcomes, i.e., overall mortality, length of admission, readmissions to hospital, satisfaction and quality of life of the patients (Phillips et al. 2004, Preen et al. 2005, Coleman et al. 2006, Ellis et al. 2011). In the medical field the most consistent experiences concern patients with congestive heart failure (Phillips et al. 2004), while in the surgical field the most significant contributions regard older subjects with hip fracture (Huang and Liang 2005), who experience multiple handoffs during care transitions across settings, on average 3.5 (Boockvar et al. 2004).
Starting from the year 2000, a large number of meta-analyses has been published about structured protocols for discharge planning (Hyde et al. 2000, Preyde et al. 2009, Hansen et al. 2011, Hesselink et al. 2012). The large Cochrane meta-analysis conducted by Shepperd et al. (2013; 24 RCTs, 8098 patients) was inconclusive, but results suggested efficacy in at least three areas, including length of hospital stay, readmission rates and patient satisfaction. Another metanalysis published by Fox et al. (2013; 9 trials, 1736 participants) showed that, compared to usual care, discharge planning programs result in a lower risk of readmission to hospital at 30 days (22% reduction) and a reduced length of stay in cases of readmission within one year (almost two and a half days); no differences emerged regarding length of first admission, mortality or patient satisfaction.
The increase in length of hospital stay and frequency of readmissions provoked by inadequate knowledge of the clinical factors linked to posthospital syndrome and non-medical reasons cause adverse effects both on the health of hospitalized older patients (increased risk of iatrogenic complications, functional decline and mortality) and on the costs to health systems.
The inconclusive evidence about the efficacy of discharge planning programs in the literature is still affected by the paucity of data from clinical settings insufficiently explored; this is due to lack of mandatory structured ministerial programs introduced in some states (e.g., USA) or to lack of guidelines on discharge planning, developed by health departments (as currently happens in the UK)(Fox 2013).
After all, even meta-analyses show a lack of data about important outcomes for the geriatric population, such as quality of care detected by the caregiver, satisfaction of community healthcare providers, functional status of the patients, rate of institutionalization after discharge, costs of hospital assistance and community care, and costs of drug consumption. On the other hand, the effect of having a DP on outcome-related complications typically associated with hospital readmission, including delirium, functional decline, pressure ulcers, hospital infections and bed rest syndrome could be relevant.
The possibility of quickly analyzing the clinical/care needs of elderly patients hospitalized for both medical and surgical reasons, and organizing care plans to be immediately activated after the acute phase, has a principal role in increasing the efficiency and economic sustainability of healthcare systems and improving quality of life for vulnerable elderly subjects needing continuity of care.