Experiences of elderly patients regarding independent community living after discharge from hospital: a longitudinal study
Centre for Allied Health Research, University of South Australia, 1 Department of Public Health, University of Adelaide, 2 Lyell McEwin Hospital, Australia, 3 Present address: Centre for Allied Health Research, University of South Australia, Australia
Objective. To describe the reported experiences of elderly patients regarding their transition from an acute hospital to independent community living.
Design. Observational longitudinal study based on semi-structured interviews conducted monthly for 6 months following discharge from hospital.
Setting. Four South Australian acute hospitals.
Patients. One hundred elderly patients who faced a long-term change in health status and/or in their ability to manage practical aspects of daily living.
Main outcome measures. Experiences in managing change in health status, social circumstances and independent community living.
Results. Few patients believed that discharge plans made in hospital had assisted their return to independent community living. Discharge planning addressed mainly formal health services rather than practical aspects of daily living. Many patients implemented innovative solutions when formal services were unavailable or inadequate. Pain, tiredness, loss of mobility, and grief over loss of previous abilities were frequent, long lasting sequelae to illness, and few discharge plans prepared patients to deal with this.
Conclusions. Elderly patients who have left hospital to face a permanent change in health status often regret that they have not been better prepared for what lies ahead in terms of more specific information about their condition, linked with practical discharge plans that prepare them for their period of convalescence. We suggest that the underlying problem is a disjunction between the multiple systems involved in hospital discharge planning, primary medical care, disability-oriented community health services, and informal community services.
Keywords: ageing, discharge (transition) planning, hospitalization, independent community living
Address reprint requests to Associate Professor Karen Grimmer, Centre for Allied Health Research, University of South Australia, City East Campus, North Terrace, Adelaide 5000, Australia. E-mail: karengrimmer{at}unisa.edu.au
Accepted for publication June 21, 2004.
This paper describes the perspectives of elderly patients discharged from hospital to home, after an illness that changed their health status and ability to manage daily living activities.
Discharge planning should involve identification of patient need and the organization of appropriate supports to assist recently ill people in transferring safely between hospital and the community, and to optimize their recuperation [1,2]. The importance of maintaining elderly people’s community independence as long as possible has been heightened by rising hospital costs, shorter hospital stays, and limited access to residential care places [3–6]. For many elderly people, admissions to hospital and concomitant use of community support services are integral to ongoing community independence [3,7,8]. However, successful integration of hospital admissions and return to independent community living requires planned effort by hospital staff, community services, patients, and their families to ensure that patients’ ongoing health and social needs are met efficiently and effectively [9–12].
Most research into discharge planning uses follow-up periods of days and weeks, thus the long-term ramifications for patients of living with changed health status, and issues of adequate preparation for this, have rarely been described in the literature [1–12]. This paper explores patients’ perceptions of their experiences over a 6 month period following discharge from hospital. The study aimed to identify patient needs and concerns throughout their convalescence, and to describe ways in which they managed the ramifications of illness.
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Methods |
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Ethical approval
Ethical approval was provided by the researchers’ universities and participating hospitals. Before discharge from hospital, or at the first post-discharge contact, subjects provided written informed consent to participate, and verbally reconfirmed this at each subsequent contact.
Design
A longitudinal observational study collected qualitative and quantitative data from patients 1 week after discharge from hospital, and then at the end of each month for the next 6 months. This paper reports the qualitative data.
Subjects
Between February and July 2000 (the period of the research project), potential subjects (patients) were identified in consultation with hospital staff from consecutive admissions in four acute hospitals. Eligible patients were >60 years of age, English-literate, and had been admitted to hospital for a condition that was presently calling into question their ability to live independently in the community. Analysis of hospital discharge figures suggested that 80–130 eligible patients would be admitted during the study period, suggesting a realistic sample size of 100.
We were interested in patients who may not yet have learned how to navigate the aged care system to obtain required community services, thus we excluded patients who had had repeated admissions for the same chronic illness. We wanted to understand the problems that patients faced when their medical problem was still recent, and before their new patterns of community functioning became established [4,6,11,12]. Patients with co-morbidities of depression and anxiety were eligible, but we excluded patients with dementia, or primary or secondary diagnoses of malignancy. No other diagnostic criteria were specified.
Data collection
One researcher (J.F.) collected all post-discharge data via telephone interviews of 
15 minutes duration. All interviews were semi-structured [13] and ranged over patients’ worries and concerns, family and social support networks, attitudes to their illness, change in usual activities as a result of their illness, availability, organization, use and satisfaction with community services, medication management, home environment, and strategies to deal with changed living circumstances. In the first interview (1 week post-discharge), subjects were asked to reflect on their knowledge of, and involvement with, hospital discharge plans, and to consider how these influenced their ability to manage independently in the community. In subsequent interviews, subjects were encouraged to reconsider issues that they had raised earlier.
Data management and analysis
All interviews were audio-taped and transcribed. Each transcript was independently evaluated by two researchers (J.F. and K.G.) for key themes. Disagreements regarding theme identification were resolved by reflection and discussion between researchers. Differences were tested between gender proportions and age, with significance set at P < 0.05.
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Sample
Hospital staff identified 163 patients as potentially suitable for this study. Fifty-six patients were deemed ineligible either during initial interview or from review of hospital records. Seven eligible patients refused to participate, leaving a sample of 100 eligible consenting subjects. Over the study period, five subjects died and six withdrew; reasons given included respondent burden (two), moving to residential care (one), and new illness (three). In total, 522 interviews were conducted.
Subject descriptors
Age was not significantly different between male and female patients [mean age 77.4 (SD 6.2) and 74.1 years (SD 8.2), respectively]. There were significantly more females (65.7%) than males in the sample. Isolating one key admission diagnosis was constrained by patients’ multiple concurrent health problems. For both men and women, heart problems were the most common reason for hospitalization. For women, the next most common reason was being ‘unwell’, whilst for men it was undefined abdominal problems. Other common admissions were non-specific ‘collapse’, bladder and bowel problems, arthritis, respiratory problems, falls, and strokes.
Transition experiences
Approximately 55% of subjects experienced an uneventful transition from hospital to independent community living, with most resuming pre-morbid functioning within 3–4 months of hospital discharge. Subsequent interviews simply confirmed patients’ continuing health status. However, despite showing resilience in the face of their health problems, the post-discharge experiences of the remaining patients were less satisfying. From interview information, we estimated that 19% subjects had at least one unplanned re-admission to hospital, related to their index admission. This paper reports on eight key issues that subjects believed constrained their transition from illness to independent community living.
Discharge planning systems
The discharge plans and the systems underlying them, described from patients’ perspectives, were similar to findings regarding discharge planning in other Australian hospitals [1,3,6,13,14]. Discharge plans in this study were generally made by hospital staff with variable input from patients, and dealt with medications, organization of community services, and equipment. Hospital staff included ward nurses, medical staff, specialist discharge planners, and allied health professionals. It seemed to our subjects that short hospital admissions, the general busyness of hospital staff, and patients’ ill health most likely constrained patient involvement in discharge planning: ‘I was too sick in hospital take much in about going home’ (Mr G). Even for those patients with uneventful discharges, very few felt that they had been discharged from hospital directly into the care of community health workers, with most patient experiences being of a post-discharge period of some isolation and uncertainty.
Key themes
In the first three interviews (months 0, 1, and 2), subjects mainly reflected on four key themes (Table 1) related to immediate management of their condition and adjusting to independence in daily activities. In the latter study months, four new key themes emerged (Table 1), related to adjustment to new circumstances and regaining community independence.
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Key theme 1: inclusion in discharge planning activities whilst in hospital. Few subjects, including those who had an uneventful return to independent community living post-discharge, felt included in planning their transition from hospital to community living.
Mrs H, a widow, recalled how worried she had been in hospital about going home alone, as she was ‘not confident about managing lots of things that never used to worry me, like paying the bills on time, going out for food, keeping the house clean, what happens if I fall?’. She waited in hospital for someone to talk with her about going home, but no-one did (‘They just told me that now my pills had been changed, I would be fine’). When she was discharged late one winter afternoon, and had to make her own way home, she ‘almost felt like giving up. Maybe this is what it is like when people make up their minds to go into a nursing home?’.
As subjects recalled, hospital discharge plans seemed related mostly to organization of formal post-discharge services. Subjects claimed that there was little attempt by hospital staff to involve them in making plans, to assist them to understand their condition and/or their changed health status, or to address practical situations they would face upon returning home.
Mr J (a diabetic) had been admitted to hospital with chest pain and left ventricular failure. One day after discharge, he was re-admitted with chest pain. He could not recall any discussion during either admission about his home circumstances, his worries, or his ability to manage at home, and no community services were organized on discharge. Two weeks after discharge, Mr J described balance problems and commented ‘My legs won’t go where I want them to go!’. In the 3 months since discharge, his children have assisted him daily with aspects of hygiene, shopping, and house and garden chores: ‘I am glad they are there—I don’t know how I would have managed without them’.
Key theme 2: transfer from hospital to home. Immediate problems for many patients on leaving hospital were returning to a house without fresh food, and with no electricity or gas (bills not having been paid) or with mess remaining from vomiting before hospital admission. Common ongoing concerns in the first few weeks were purchasing, preparing, and eating food, paying bills, moving safely around the house, garden, and neighbourhood, sleeping comfortably, and maintaining household and personal hygiene.
The timing of the commencement of formal community health services after discharge varied from several hours to several months, with the average wait being 4–5 weeks. The most efficient way for subjects to commence receiving post-discharge services was to have already been receiving them before admission. Delays in post-discharge provision of services were experienced by almost all subjects who were ‘new’ to the community health service system (i.e. had not previously used it).
Mrs O was 73 years old and lived with her husband in the country. She had severe chronic obstructive airways disease. She used a walking stick when breathless. Mr O had a bad back, but did some light housework. Their son regularly did the vacuuming and cleaned the bathroom when Mrs O was unwell. Mrs O was admitted to hospital following a chest infection, and she was discharged with home oxygen. Mrs O was told she would be referred to community health services ‘but there is a six month wait’. On returning home, Mrs O was too unwell to commence any of her pre-hospital tasks, and showering and dressing left her exhausted. Mrs O’s husband and son assisted her with showering, dressing, and moving around the house, and undertook all her former household duties.
Consequently, 40% of subjects reported requiring extensive assistance from untrained people (neighbours, family, and/or friends) in the first few days following discharge for hygiene matters, wound management, and meals provision. They reported the confusion and embarrassment they felt (often within minutes of returning home) when they were confronted with tasks they couldn’t physically manage.
Mrs W was a 77-year-old widow who lived in her own house, with a male rent-paying boarder who was also elderly and was a friend of the family. He had moved in 18 years ago when her husband was alive. Two months after her discharge from hospital, the boarder expressed his dissatisfaction with the hospital. He stated that staff had not explained fully the things Mrs W would require help with: ‘I am only the boarder—I can’t do the personal things’. He felt it would be inappropriate to assist Mrs W with showering or dressing, although he was comfortable with preparing meals occasionally, and helping in the garden.
Key theme 3: provision of information about medication and condition. There was a widespread lack of understanding by patients about the ramifications of their medical condition, relating to what was actually wrong with them, tasks that could safely be undertaken, recuperation time, use of medications, how long they could expect to wait for formal community health services, who could assist with household tasks, and how they could help themselves to recover effectively.
Key theme 4: preparation for convalescence. Subjects identified a range of concerns and frustrations in the first 2 months post-discharge, reflecting their generally unwell state, and confusion and anxiety that resulted from their (sometimes dramatically) changed health status [15–18]. Three core concerns related to convalescence were repeatedly reported throughout the study period: tiredness, pain, and loss of mobility. These concerns were inter-related, for instance pain often constrained mobility, which required abnormal physical effort to overcome, resulting in ongoing tiredness. Compromised nutrition, hygiene, sleeping, and social contact were the common result.
Mrs S was hospitalized for 3 days following a heart attack. In the first week home she complained of feeling ‘extremely tired’. She used to get up early and then have a nap late in the morning. She also required an afternoon nap. One month after discharge, she described her functioning as a ‘wee bit wobbly but managing’. Her tiredness was gradually disappearing since her general practitioner (GP) altered her medication.
From the subjects’ perspective, discharge planning activities in hospital most commonly addressed compromised mobility (by prescription of mobility aids). Approximately one-third of the subjects had been provided with mobility aids before leaving hospital; however, in 25% of these instances the aids were considered by subjects to be inappropriate or unsafe (e.g. too wide for doorways, or got caught on mats or stairs). The aid was then generally discarded. Some subjects, whom it seemed could have benefited from a mobility aid, refused to use one, fearing dependency, and innovative mobility strategies were put in place, such as deliberately placing furniture to assist navigation around the house.
Mr and Mrs A were hospitalized after a severe car accident in which they both suffered fractures. The winter cold aggravated their pain. Neither of them could get out of bed without pain, and walking from bedroom to bathroom was very tiring. Neither had been offered walking aids or rails. They both were sleeping upright in lounge chairs next to the heater for warmth, and so as to be able to get up more easily during the night.
Few subjects appeared to know about adequate pain self-management, including appropriate medication use (type, frequency) or non-medication management (e.g. gentle exercise, relaxation, heat, cold, massage, bandaging, positioning). Common concerns about pain medication were reluctance to take prescribed analgesia for fear of dependency and interaction with other medications, expense, and lack of confidence in medication effectiveness. Up to 20% of subjects reported taking less than the prescribed dose of analgesia to save costs.
Mrs X, a widow with few family supports, had been hospitalized for severe back pain after a fall. She struggled with ongoing pain, and by 6 months post-discharge she admitted that she was taking a cocktail of pain medications, and had to take these before the pain hit, to ‘stay ahead of the pain’ so that she could manage her daily household activities without asking for help.
Subjects were surprised by how much they struggled with basic hygiene in the first few weeks post-discharge. Few subjects received assistance from formal health services in these first weeks at home, and thus they often adopted abbreviated bathing strategies (‘topping and tailing’). The effort of maintaining pre-admission hygiene standards was tiring, depressing, and dangerous, particularly when using poorly fixed towel rails or toilet-roll holders as supports, or when bathrooms were not designed to accommodate someone with decreased mobility.
Mr F told us that ‘the bathroom is a bit small for all my ‘gear’ (frame, dressings, etc.)—I have to be careful that I don’t trip up when I get in and out of the shower. I am glad that I have the taps to hang on to in the shower so I can have a good wash of my ... (posterior)’.
Key theme 5: grief over reduced ability. For the first time in their lives, many subjects faced coming to terms with permanent changes in their physical abilities, for example reduced exercise tolerance or partial loss of limb function. Despite this, it appears that they received little counselling either in hospital or the community about the process of adaptation to these permanent changes.
After hospitalization for a ‘slight stroke’, Mr Z could no longer drive. This upset him greatly. He missed driving a lot and complained of feeling housebound. He felt depressed because he couldn’t ‘just get in the car and go off somewhere, anywhere!’. Last week he had resorted to reversing his car up and down the driveway.
Some subjects seemed to be experiencing a grief reaction for lost abilities, and few subjects reported being helped in either hospital or the community to reach an acceptance that they may never completely regain their pre-morbid status. They often wrongly presumed that participation in an outpatient ‘rehabilitation’ program (e.g. for stroke patients) would ensure a complete recovery, and were disappointed when it did not.
Key theme 6: regaining independence in the community. Many subjects displayed a fierce determination to maintain their independence at any cost. While this persistence may have assisted some to deal with difficult situations, it may also have acted as a negative force, inhibiting patients with real and unmet needs from seeking services that could improve their quality of life, and enhance their safety and community independence.
Two weeks after discharge, Mr Q was still waiting for contact from the hospital physiotherapist about ‘outpatient rehabilitation’. Meanwhile, without his GP’s knowledge, he had set up a rowing machine and exercise bike in his shed. He was using this daily to build up his strength: ‘I do it until my body aches’.
In the last few interviews, subjects identified important community resources related to health concerns and activities of daily living, which they believed would help them regain their independence.
Health concerns
The GP was the most consistent information source and service coordinator post-discharge. All subjects identified at least one GP whom they consulted regularly, and >75% reported having a long-standing relationship with their GP. Approximately 10% of subjects reported consulting more than one GP, often for specific problems or services (for instance women might consult a female GP for gynaecological conditions only). Approximately 33% of subjects reported that the GP telephoned or visited them at home within the first 48 hours after leaving hospital to ensure that they were ‘settled in OK’. However, some subjects did not hear from their GP until they initiated contact because their GP was unaware of their hospitalization.
Subjects often expressed a concern that when GPs had known them for a long time, they did not appreciate the extent of their changed health status, and relied instead on previous knowledge to manage presenting problems. This made it difficult for subjects to enquire about issues that had not bothered them before their hospitalization. Dissatisfied subjects rarely changed GPs, however, as they worried about ‘asking for their records’ (Mrs Z) or finding another GP who would provide them with better service (such as ‘coming out at night if there is a problem’; Mrs AC).
Ongoing ramifications of illness (pain, tiredness, depression, lack of confidence) were repeatedly found to be issues that subjects failed to bring to their GP’s attention. Patients perceived their GP to be too busy or not able to address these problems adequately, and therefore they prioritized their problems so that their most pressing concerns (such as obtaining new prescriptions) were always dealt with before consultation time ran out.
Appropriate formal community health and support services were rarely in place immediately after discharge from hospital. Twenty percent of subjects received these services within 4 weeks of leaving hospital, 70% received services within 2–4 months, and the rest had to wait for longer.
Before hospitalization, Mrs M had been receiving formal home care assistance. She had her house cleaned once a fortnight, but did the dusting herself. Mrs M has ‘heart problems’ and the ‘medication causes balance problems’. She was hospitalized for five days following a fall. The hospital organized home-delivered meals from a community organization, a shower chair and an indoor walking frame. One week after discharge, Mrs M was pro-active in seeking out resources and initiating action. She didn’t like the frame that was supplied, and the shower chair was too big for her shower cubicle. She decided to purchase a walker and shower stool. She cancelled the delivered meals as she found the food ‘too boring’. Through a friend she found out about a lady who cooked meals privately for the elderly. She commenced this and really enjoyed the food.
Considering activities of daily living
Subjects’ most commonly expressed needs immediately following discharge were not for ‘health services’ per se, but for assistance with practical aspects of daily living, such as shopping, meal preparation, household chores, banking and paying bills, gardening and pet care.
Two weeks after discharge, both Mr and Mrs A reported to us that things were going ‘terribly’. They claimed that while in hospital no-one offered them any advice on how to manage, or what home help was available. They had problems ‘with the everyday stuff’. Because both of them had fractured ribs, they couldn’t do the washing or hang it out, and neither could stand for very long to organize anything to eat: ‘It is a day-by-day existence at the moment!’.
Informal services, often offered privately within the community (such as home delivery of groceries, assistance with gardening, housecleaning, household chores, rubbish removal, meal provision), were more responsive to needs and more valued by patients than formal community support services. Subjects seemed generally to rationalize the financial cost of private services against services’ timeliness, responsiveness, willingness to undertake a range of tasks, the physical burden for patients when undertaking these tasks, and the waiting time for formal services to be put in place. Information about informal services was often obtained by word-of-mouth or local advertising (letterbox drops, local newspaper).
Mrs W was knowledgeable about services available in her area and had good insight into how to use them so that she continued to function safely at home. She regularly gathered information about services from friends, junk mail, the hospital, local council, and community organizations ‘and then makes informed decisions’. She provided other elderly people with information about what was available, using her extensive (telephone) social network.
Expectations of independence
Irrespective of the nature and level of post-discharge services, and whether these met subjects’ needs, we identified a transition period (usually after the first 2–3 weeks post-discharge) when subjects felt that they should have become more independent. This often coincided with a review appointment with their medical specialist, and seemed to reflect a point in the convalescence when health status stabilized medically. Subjects then often commenced tasks for which they were still unprepared (such as shopping, cooking, and showering alone), and as a consequence became more tired and discouraged.
Key theme 7: resuming social contacts. Many subjects keenly felt a decrease in their social functioning as a result of their changed health status, and frequently reported not feeling ‘useful’ any more. Social contacts that they had previously valued, such as membership of community groups, voluntary activities, or visiting friends, often ceased. This commonly occurred 2–3 months after discharge from hospital, at a time when many subjects seemed to be most frustrated with their inability to regain pre-morbid health status and social functioning. Despite many subjects identifying the significant impact of ceasing social contacts on their sense of well-being and ‘belonging’, many seemed reluctant to explore alternative activities, citing fatigue, loss of mobility, or future (anticipated) health constraints as key barriers.
Mrs W reflected that ‘A few months ago I was involved with so many things. Now I see no-one, my only contact is the telephone. It is like no one even remembers that I am alive. Only its just my legs that don’t work so well, not my brain!’.
Key theme 8: improving the transition process. Over the study period, subjects identified information and community services that, had they been part of discharge plans, could have improved their transition to independent community living. These are outlined in Table 2.
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Improved community organizational supports, identified by our patients as potentially assisting others to regain their independence in similar circumstances, are outlined in Table 3.
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Discussion |
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This study yielded rich information from patients after they had been discharged from hospital to deal with the ramifications of a life-changing illness. This study adds to the current body of knowledge regarding the extent to which hospital-based discharge plans prepare patients to deal with changed health status and/or ability to function adequately in the community. This study also presents further evidence (from patient perspectives) of the lack of cohesion between hospital and community health systems [1,6,11–14].
All key themes highlighted practical aspects about the transition from hospital to the community, which seemed to be overlooked by hospital staff in discharge plans. Many patients reported not being provided with sufficient information whilst in hospital about many aspects of recuperation. Irrespective of the veracity of these claims, it was apparent that advice had not been provided to hospitalized patients in a way that ensured its retention or that assisted them to help themselves after discharge. With early discharge from hospital now common [5,7], more of the convalescent period occurs in the community. For many subjects, successful convalescence seemed heavily reliant on regular assistance from unskilled family members and friends, or on serendipitous access to information about community services or equipment. In particular, common reports of ongoing mobility problems, tiredness, pain, difficulties maintaining hygiene standards, and lack of access to appropriate community support services appeared to constrain not only successful transition from hospital to the community, but also adaptation to altered health status.
Formal community services rarely addressed subjects’ everyday needs, and even specialist assistance with hygiene, medication, and wound dressing was only usually available every few weekdays, and not on weekends or public holidays. Thus, even when patients were in receipt of formal support services, they still needed to manage some aspects of health tasks for themselves. There were a number of instances where formal community support services seemed inappropriate and poorly timed, which indicated that imminent release from hospital with changed health state may not be a key indicator of priority access to formal community services. Informal and private services often seemed to be more responsive, flexible, and tailored for older people’s needs than formal community support services, although accessing information on any community service seemed overwhelmingly complicated for many unwell patients. Commonly, subjects perceived themselves to be caught in a complex web of community support service factions, where prioritization, eligibility criteria, and availability of community services related more to service providers dealing with pressure on scarce resources than to recognizing and meeting real patient needs.
Patients reported as most helpful, during early post-discharge days, being relieved of shopping, meal provision, and basic house cleaning (often undertaken by family members or friends). This concurs with findings of other studies, where social and practical supports are most important in helping an elderly ill person remain in their own home [19,20]. Thus, recognizing the importance and availability of these supports seems an essential element of formal discharge planning.
The importance placed by patients on timely attendance at formal rehabilitation programs post-discharge should be considered in light of their perceptions that lack of improvement is related to lack of access to formal rehabilitation, rather than to the nature of their condition. Thus it seems important in discharge planning that patients are educated that ‘rehabilitation’ is often about achieving a different level of functioning, rather than regaining pre-morbid status. Moreover, formal rehabilitation programs could be coupled with home programs that incorporate activities of daily living to optimize benefits, thus discharge plans should incorporate ideas to assist patients to take an active role in their ‘rehabilitation’.
Patients frequently had little idea about the time period associated with regaining safe independence, and many seemed to put their health at risk by undertaking activities for which they were not yet ready. More information in hospital about their condition, and the length of time it could take them to feel well (even after their condition had stabilized medically), would have assisted subjects to stage the pace with which they recommenced activities of daily living. This information may well address what we termed ‘the grieving process’, which seemed to occur when patients recognized that regaining pre-morbid health, physical, and social functioning was unlikely.
The findings regarding the role of the GP in patients’ recuperation mirrored previous reports [21–23]. The importance of the GP in assisting and monitoring progress was particularly relevant to our patients. Of concern, however, were patients’ responses to fitting complex health needs into short appointment times, such as prioritizing problems that they brought to their GPs’ attentions. This meant that potentially serious issues such as ongoing pain and tiredness often went unreported, thus allowing situations where patients managed themselves inappropriately and unsafely.
The limited number of mobility and assistive aids in place at time of discharge concurred with findings of other studies, which report a lack of basic assistive devices (such as lavatory rails) in homes of elderly ill people [4,8,19,20]. When in place, these devices are reported to slow decline in functional status [16–18]. The lack of organized follow-up by hospital staff after discharge, and the lack of cohesion between hospital and community services provided few opportunities for reassessment of the continued appropriateness of assistive devices.
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Conclusion |
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This study identified patients’ perspectives on a range of issues regarding their return to sustainable independent living in the community following illness. The study findings suggest that discharge plans made in hospital for patients who face a permanent change in health status should focus on practical community functioning over an extended recuperation period.
It seems that a better system is required in hospitals in which patient needs are recognized, appropriate information is provided in a manner that has maximum impact on knowledge retention, and follow-up resources and services are mobilized so that patients’ recuperation is optimized. Hospital staff planning discharge should recognize that they are working at the junction of four systems, namely the hospital, general medical practice, disability-oriented community health services, and informal community services. Community health and support systems should be integrated with hospital discharge plans to ensure effective and efficient follow-up that prevents patients losing their confidence in managing independently.
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Acknowledgements |
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The medical and nursing staff at the four participating hospitals are acknowledged for their ready assistance in identifying eligible patients. The patients and their carers are thanked for their willingness to provide extensive and repeated information about their experiences following discharge. The Department of Human Services, South Australia (SA) and the Office for the Ageing, SA financed this study.
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References |
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