Discharge Planning and the Journey from Hospital to Home

Improving the patient journey from hospital to home and improving communication and coordination between professionals are critical in the support of patients returning home. Clear and timely hospital discharge information, including medication reconciliation, are key to this improvement. The advent of new professions such as care managers and practice facilitators in primary care is an important development in supporting patients at home with establishing personalized medical plans, coordination of professionals and the navigation of the healthcare system.

Patients at risk of poor outcomes after discharge may benefit from a comprehensive discharge planning protocol implemented by advanced practice nurses (Tibaldi et al. 2009; Shepperd et al. 2009); one in five hospitalizations is complicated by a post discharge adverse event. In one successful intervention, a nurse discharge advocate worked with patients during their hospital stay to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education with an individualized instruction booklet that was sent to their primary care provider. A clinical pharmacist called patients 2–4 days after discharge to reinforce the discharge plan and review medications. Participants in the intervention group had a lower rate of subsequent hospital utilisation (Jack et al. 2009).

Training of Patients and Carers

Recently a member of one of our families had a cancer removed and was left with a substantial wound which needed regular dressing. The person was discharged home one day after a successful operation with the patient's partner, after minimal instruction, being responsible for the dressing of the wound, managing a drain and dealing with an incipient infection. This would, of course, have been unthinkable a few hours previously when the patient was in hospital. Fortunately the patient's partner proved adept at these rather difficult tasks. The early discharge was well intentioned and in the patient's best interest but the story illustrates how quickly professional standards are lost once the patient is discharged home.

In some settings, particularly in mental health, there is a much stronger emphasis on responsibility for the patient continuing beyond discharge and including preparation for return to home and life in the community. Physical healthcare is moving into the home and community but often without this mind-set of anticipation, preparation and continuing responsibility. If patients and carers are to take on essentially professional roles, albeit only with specific tasks, then surely they need to be trained to do so? In India, families have been co-opted as part of the workforce to help care for the patient but, in recognition of this role, they are prepared and trained (Box 8.2).

Box 8.2. Training Families to Deliver Care

At Narayana Health families are seen as having a crucial role in the recovery of patients following surgery. They operate a 'Care Companion Programme' to harness family members' potential and position them as an integral part of the patient's recovery. A free structured training programme, tailored for those with low literacy levels, provides family members with simple medical skills such as monitoring vital signs, encouraging medicines adherence and supporting physical rehabilitation. The programme improves the quality and hours of care, leverages an untapped workforce, reduces costs and is universally transferable. Five thousand people a month are being trained on the programme. Given the desire to place patients and families at the centre of their care in the NHS, such training seems a practical way to help achieve it.

Adapted from Health Foundation (2014)

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