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Background Paper: A Framework for Effective Discharge December 1998

BACKGROUND

As part of its mission the Department of Human Services aims to enhance outcomes by purchasing effective, high quality acute health services which are accessible and relevant to the needs of individuals and local communities.

The Victorian Government and governments around the world are placing greater emphasis on accountability for expenditure of public funds on health care services. The challenge for government is to determine how to measure the performance of health care services in terms of efficiency and effectiveness, to contain costs and at the same time maintain and enhance the quality of patient care.

It is in this context that the Department is increasingly focussing on the quality of care provided in public health services. The Quality Branch of the Acute Health Division was established in late 1997 to develop policy and strategic approaches so that acute care providers can improve the safety, accessibility and effectiveness of public hospital services. The work of the Branch involves:

• assisting and supporting quality improvement which is supported by best available evidence of effectiveness;
• promoting consumer information and involvement; and
• developing measures of quality in public hospitals which are meaningful at a system wide level.

This work depends upon active collaboration between the Department and health care managers and clinicians.

INTRODUCTION

Effective discharge is a priority area for the Department in 1998-9 and beyond. The Effective Discharge Strategy is supported by funding recently received under the Australian Health Care Agreement for quality initiatives. The Strategy is a joint initiative of the Aged Care Branch of the Aged Community and Mental Health Division and the Quality Branch of the Acute Health Division and applies to acute hospitals, aged care services and Multi-Purpose Services (MPS). For the purposes of this Strategy, aged care services include extended care centres and aged care wards in general hospitals.

In the past decade much work has been undertaken by health care providers to improve care management processes, including discharge planning. There is, however, considerable variation in practice within and between hospitals and a dearth of information about the effectiveness of these processes. The Strategy represents a systematic approach to understanding, measuring and improving discharge planning processes and their outcomes. This will be achieved by:

• Supporting health care providers to review and improve discharge processes and practices; and

• Developing robust performance indicators which measure the effectiveness of discharge processes.

The initiatives for the first year of the Strategy are:

1. Discharge Improvement Plans - Health Care Networks, non-network hospitals, aged care services and MPS are to develop and implement plans designed to improve current discharge processes and practices. Funds will be allocated to develop and implement these plans.
2. Audit of patient records to assess current discharge practice in acute hospitals, aged care services and MPS.
3. Performance bonuses - allocated on the basis of the findings of the audit to the best performing acute hospitals, aged care services and MPS.
4. Performance indicator development - focusing on indicators of effective discharge processes, including patient and carer satisfaction.

An initial investigation has been undertaken by the Quality Branch involving a preliminary literature review and consultation to define effective discharge and the processes involved in achieving it. This background paper summarises the findings of this investigation and provides the basis for the Effective Discharge Strategy. While the paper focuses primarily on discharge from acute hospitals, the principles discussed can be applied usefully to aged care services.

The Service Delivery Context

A number of factors underpin the need for an effective discharge strategy. These include:

1.Decreasing length of stay:

The average length of stay in hospital has been declining since pre-casemix funding in Victoria. The average length of stay decreased by 34 per cent between 1987-8 and 1994-5, from 6.4 to 4.2 days. Since that time, the average length of stay has decreased a further 5 per cent to its current estimate of 3.98 days. However, over this period, same day separations have been increasing at a steady rate contributing to this diminishing average. There is some evidence that length of stay for multi-day admissions is now plateauing or decreasing at a lesser rate. There is considerable variation across hospitals in length of stay for some diagnosis related groups, suggesting variation in clinical practice and care management processes.

Reduction in length of stay is attributed to new technology and pharmacology, new clinical practice and more efficient work practices and processes. However, views are also expressed by consumers, carers and service providers that reduction in length of stay has been driven more by budgetary constraint than concern with improved quality of care. There is insufficient evidence to inform this debate, however, it is generally agreed that shorter hospital stays demand good discharge planning particularly for people with complex care needs. There is evidence to suggest that time spent in hospital concerns people less than the extent to which they are prepared for discharge and the availablity of post discharge support. The Victorian Public Hospital's Patient Satisfaction Survey, conducted in 1995 found that the majority of patients perceived their length of stay in hospital to be 'about right'. In contrast, 40 per cent of patients believed their discharge to be inadequate in terms of the information they received and the information sought about their need for assistance at home following discharge. Of the patients for whom such assistance was seen to be needed, only 67 per cent reported that the hospital organised outside help on discharge.

2. Integration and continuity of care:

Changes in treatment and hospital practice mean that hospitals are now frequently described as one increasingly specialised, component of a broader health care system. Care previously provided in the hospital is now provided in the community both before, during and after admission. This shift demands an integrated approach to the planning and delivery of services to ensure continuity across organisational boundaries.

Over recent years, hospitals have improved management processes to streamline care. This needs to be extended to include the coordination of care between the hospital and general practitioners (GPs) and other community providers. Discharge planning operates at this interface. To facilitate integration, hospital discharge protocols need to be developed with active involvement of GPs and other community providers.

Continuity of care is of particular importance for people who have ongoing needs for care and it is imporant that care planning processes have the capacity to discriminate and respond to differing levels of need for coordination and post-discharge care.

DEFINITION

'Discharge planning' is the term most commonly used to refer to a process of which the planning activity is one element. This process is generally thought of as "the critical link between treatment received in hospital by the patient, and post-discharge care provided in the community."

The Strategy adopts the term 'effective discharge', which includes discharge planning and shifts the focus to outputs and outcomes of the process, rather than input.

COMPONENTS OF THE EFFECTIVE DISCHARGE PROCESS

"Discharge does not begin on the day a decision is made to send a patient home. It is not a single event".

It is generally accepted that discharge planning should start prior to admission (for planned admissions), or at the time of admission (for unplanned admissions), and that it ideally comprises these four stages:

1. Assessment of patient physiological, psychological, social and cultural needs.
2. Care plan development - identifying and documenting discharge strategies as part of an integrated planning process.
3. Implementation of plan - arranging for the provision of services, including patient/family education and referrals
4. Follow-up post-discharge and evaluation of the effectiveness of the discharge strategies

This is a systematic, problem solving approach to providing care. The care plan provides the means by which hospital and GPs and other community providers can plan and organise their activities around the individual needs of the patient. The follow-up and evaluation stage provides the feedback loop that enables the effectiveness of the discharge process to be measured.

The following discussion lists the activities that are consistently identified in the literature and hospital procedure manuals as components of these stages.

Assessment

Hospital care planning begins with, and is reliant on, "a thorough, accurate and complete assessment by all those involved with the patient in hospital". Comprehensive assessment considers the patient's physiological, psychological, social and cultural needs and requires an understanding of the patient's home and social circumstances, such as:

• available family resources and preferences (ie. whether the family/carer is willing and able to provide the care and support needed to recuperate);
• cultural, linguistic and religious needs;
• home environmental impediments to recuperation;
• existing responsibilities not being met due to admission (ie. child care, pets, work);
• capacity to perform activities of daily living; and
• the community services that were used before admission and likely to be needed on return home.

Sources of information include the patient, family, carers, GP and other community providers delivering services and care to the patient prior to admission. An assessment of the patient's post-discharge needs may also involve a home visit by hospital staff, such as the occupational therapist, to assess the environment to which the patient will be discharged.

Risk screening

The discharge procedure for many patients leaving hospital may be relatively simple and does not require a comprehensive assessment or plan. Targeting or screening for 'high risk predictors' is used to identify patients in need of more comprehensive discharge planning and service provision to support their return home. Risk screening tools have been developed to assist in this process.

The use of risk screening tools ensures that resources are used in the most appropriate way and reduces the provision of unnecessary services (such as a comprehensive assessment). This is particularly relevant in hospitals where the discharge assessment, planning and implementation function is separated from the ward, for example, where there is a designated discharge planner or planning team to whom complex cases are referred.

Care plan development

Discharge planning is that part of the hospital care plan that specifies strategies for addressing actual and potential problems identified at assessment that the patient will face upon leaving the hospital.

In the context of this paper, the reference to 'care plan' is intended to encompass treatment strategies identified by medical, nursing and allied health professionals. Care plans can take a variety of forms including critical pathways, clinical pathways and care maps, which are terms used interchangeably to describe an approach to care planning that enables quantitative analysis of the patient's progress against expected outcomes.

In determining the estimated discharge date, the intensity and type of the patient's ongoing needs for care and services has to be matched with the availability and capacity of the GP and other community providers to respond. Ideally, to ensure the patient's safe discharge, their return home may need to be delayed until such services can be organised or until the patient's recuperative needs are less intensive.

Effective care planning is said to be based on the following principles:

• Patient and carer involvement

The patient, family and other carers should be actively involved in the care planning process. This ensures that their needs and preferences are taken into account. In order to do this the patient, family and carers must receive information on their condition, treatment options, associated risks and anticipated outcomes.

• Community provider involvement

An important determinant in discharging patients on the day planned is the capacity of the GP and other community services to provide care given the patient's level of dependence and care needs. The GP and other community providers need to be actively involved in the development of the patient's discharge plan and consideration should be given to:

• The suitability and capacity of the GP and other community providers to meet the post discharge needs of the patient in terms of expertise and resources.
• Timing discharge to coincide with the operating hours and availability of community services.
• Providing adequate notification to the GP and other community providers to ensure that services will be in place by the estimated discharge date.

Implementation of the plan

Co-ordinating and implementing discharge activities can start as soon as the care plan is developed. Certain strategies may be implemented even before admission. The activities related to preparing the patient for discharge include:

• Providing information and education to the patient and the family/carer in the appropriate language, verbally and in written form relating to:

• the anticipated course of treatment and discharge date;
• ongoing health management;
• an appropriate post discharge contact to answer queries and address concerns;
• medications;
• the use of aids and equipment;
• follow-up appointments;
• community based service appointments;
• possible complications and warning signs; and
• when normal activities can be resumed.

• Arranging referrals to hospital-based internal services (such as radiology, pharmacy, occupational therapy) and external agencies or services (such as Meals on Wheels, Home and Community Care (HACC), GP, Maternity and Child Health Service).
• Initiating two-way communication between the hospital and the GP and other community providers to ensure such services are available and in place for the patient to use when needed post discharge.
• Preparing and delivering discharge information (discharge summary) to the patient and the GP and other community providers to assist them in organising service delivery. This may include a description of the unresolved, ongoing problems listed on the hospital care plan, key test results, and medication regime, emergency contact person, contact number and availability.
• Discussing the discharge information with patients to ensure they understand the care plan, medication regime and so on.
• Confirming transport arrangements from hospital to home at least the day before discharge.
• Contacting the family/carers, GP and other community providers at least the day before discharge to confirm that the patient is being discharged and to ensure that services are activated or re-activated.

On the day of discharge, activities include:

• Updating information in the discharge summary if required (including issues to be followed-up by the GP and other community providers), giving this to the patient and forwarding it to the appropriate agencies.
• Dispensing sufficient medication (and other supplies if required to manage recuperative needs) to last until the patient's next appointment with their GP (as arranged by the hospital).
• Completing discharge check list to ensure all of the above activities have been carried out.

Models of care

The discharge process is implemented within a variety of models of care. For example, 'primary nursing' is a model of care that leaves the responsibility for planning and implementing patient discharge with the nurse who is the principal carer in hospital. Alternatively, a dedicated discharge planner may be employed to perform this function either by co-ordinating a discharge planning team or facilitating discharge through an inter-disciplinary team. 'Case management' may be utilised for patients with more complex needs for care. The feature common to these approaches is that one, designated person or team assumes responsibility and is accountable for the effective discharge of patients.

Follow-up post discharge and evaluation

The purpose of following up a patient after they have been discharged from hospital is two-fold:

1. To evaluate the impact of the planned interventions on the patient's recuperation and possibly identify recurrent and new care needs.
2. To assess the effectiveness and efficiency of the discharge process.

The care process requires that all planned interventions are monitored for their impact on the patient (as identified in the care plan). Follow up of patients post discharge (either via telephone and/or contact with the GP and other community providers) provides the opportunity to find out if the problems identified as requiring intervention post discharge were adequately addressed and to deal with any new problems. It also provides the opportunity to reinforce teaching initiated in the hospital and provide assurance to the patient and their home carers. This part of the discharge process is key to ensuring continuity of care for the patient.

The expected outcomes identified on the care plan would inform the questions asked of the patient. For example, an exercise regime initiated and incorporated in the care plan by the physiotherapist may be expected to produce an improved range of motion of a limb three days after discharge. The patient would be asked if they are exercising and if this result has been achieved.

In addition to questions specifically related to care outcomes, the following questions may be asked to gauge the effectiveness and efficiency of the discharge process:

• Is the patient coping?
• Do they have any questions?
• Has the patient received the services arranged by the hospital and when?
• Is the carer able to provide adequate support?
• Has the patient visited another hospital, emergency department or GP since discharge?
• Has the patient received services other than those arranged by the hospital?
• Were they satisfied with their discharge and post discharge care?

OUTCOMES OF EFFECTIVE DISCHARGE

The evaluation and follow-up stage of the discharge process provides the opportunity to evaluate, not only the effectiveness of the discharge process, but also the effectiveness of the hospital intervention. There are clear benefits in practising effective discharge, such as improved efficiency, better health outcomes and improved satisfaction for patients. The following lists the outcomes of effective discharge interventions that were most often identified in the literature and studies examined:

• Reduced unplanned re-admission.
• Reduced mortality.
• Better quality of life.
• Improved satisfaction of patient, carer, GP and other community providers.
• Reduced length of stay.
• Improved independence post discharge reducing likelihood of admission into supported accommodation or residential care, and/or better utilisation of community services.

PERFORMANCE INDICATORS OF EFFECTIVE DISCHARGE

In order to purchase effective health services, the Victorian Government needs to monitor whether effective services are being delivered. Care planning and co-ordinated, multi-disciplinary discharge processes should be considered integral to health care provision. These processes are associated with good outcomes.

A distinction is made between variables that indicate that specific tasks are being undertaken (process indicators) and those that indicate whether the process was effective (outcome indicators). The evidence suggests that the components identified in this paper (process) contribute to achieving effective discharge and the associated benefits described as outcomes under section 5. In view of this, it is considered sufficient, at least in the short term, to monitor the performance of these tasks.

Work is required to identify and test indicators that show that effective discharge is planned and implemented. The following areas parallel the four stages that comprise effective discharge as defined above, and warrant further investigation.

• An assessment is carried out which includes an accurate account of the patient's post-discharge recuperative needs.
• A comprehensive care plan is developed which includes strategies relating to the patient's post discharge needs.
• The following information is provided in the appropriate language, both in writing and verbally to the patient, family/carers, GP and other community providers prior to discharge:

• the reason for admission;
• anticipated discharge date and time;
• anticipated outcomes and implications for return home;
• self-management procedures for convalescence, including medical regimen and wound care;
• follow-up appointments needed after discharge;
• danger signs and how to deal with them;
• a contact person for more advice, information or help; and
• when to resume normal activities.

• The GP and required community providers are identified and notified of impending discharge and receive all necessary medical and social information to enable continuity of care.
• Support and care (including aids and equipment) provided to the patient post discharge match that identified on the care plan (discharge plan).
• Patient receives a follow-up contact.
• Patient receives the level of support required post discharge (from their own perspective, from the perspective of their GP and other community providers).
• Some form of assurance that the carer and/or community providers are willing and able to provide the level of care and services needed for the patient's recuperation.

CONCLUSION

On the basis of a preliminary investigation, this background paper provides a framework for consideration by acute hospitals and aged care services to assess and improve their discharge processes. While there is general consensus as to what comprises effective discharge, there are still a number of issues that require further consideration and these include:

• Active involvement of patients, family, carers, GPs and other community providers in the development of discharge protocols and plans.
• Improvement of information and communication systems to enhance integration between acute hospital and GPs and other community providers.
• Development of indicators and the means to record these so that the effectiveness of discharge can be measured.

To progress toward systematic effective discharge from Victorian hospitals and aged care services, the Department of Human Services has developed a strategy which includes:

1. A stock-take of current discharge processes and practice in Victorian acute hospitals, aged care services and MPS.
2. Development and implementation by acute hospitals, aged care services and MPS of discharge improvement plans.
3. Development of indicators that measure effective discharge processes and practice.
4. Rewarding on the basis of performance.

This process will allow current practice to form a baseline with which to measure improvements. As performance indicators are developed and implemented, funding will increasingly be contingent upon performance relative to these indicators.

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