There is evidence that a significant percentage of older people may be medically ready for discharge, but have to stay longer because of the absence of suitable housing or care supports. This has implications both for the patients' wellbeing and cost to the health service. There is evidence that better discharge planning can have positive effects on the efficiency of the discharge and the reduction of problems that often follow from hospitalisation for older people.
Due to a demand for greater turnover in hospital beds the issue of inappropriately delayed discharges has become the subject of discussion in a number of countries including Ireland. According to Activity in Acute Public Hospitals in Ireland 2006 Annual Report, the total in-patient average length of stay generally increased with age for both men and women, peaking at 13.9 days for people aged 85 years and over who were discharged. The average stay for people over 65 was 11.3 days, four times that of the 45 to 64 age-group and over twice the average stay of 5 days for all patients (ESRI 2006).
Although there is no agreed definition of what constitutes ‘delayed’, studies in the UK show that contributory factors include; delayed placement into institutional care after completion of an assessment; a reduction in numbers of beds available in nursing homes, problems in funding from social service budgets, and delays in assessments from therapists or social services, for community services, or for equipment to be ordered, delivered, and installed (Black and Pearson 2002).
A recent UK study looked at the issue from the perspective of older people and found that many patients actively or passively relinquished their involvement in the processes of discharge planning because of the perceived expertise of others and also feelings of disempowerment linked to poor health, low mood, dependency, lack of information and the intricacies of discharge planning processes for complex community care needs (Swinkels and Mitchell 2009).
Discharge from hospital is not always a smooth process and studies from all over the world have reported that many older people who have been discharged from hospital to home, experience a range of problems in the first weeks after their return home. Problems after discharge include lower levels of independence in activities of daily living, difficulty with reading medication labels, not getting the help they needed, not being aware of available services, informational needs, symptom distress and emotional problems such as anxiety and uncertainty These problems frequently lead to further complications and unplanned hospital readmissions (Mistiaen et al 2006).
In Ireland, the PA Consulting Acute Hospital Bed Capacity Review found that discharge planning was only in place for 40% of all patients. A number of 'discharge interventions' have been developed in other countries which are aimed at easing the process of the discharge itself or at preventing, easing or solving problems in patient's functioning after discharge or preventing readmission to the hospital and treatment of post discharge problems. The types of intervention can be classified in two groups: discharge preparation and discharge support.
Discharge preparation generally takes place during the hospital stay and it involves organizing care and preparing patients in such a way that the length of hospital stay is as short as possible for most patients, that the condition of most patients is such that they can be discharged home and not into institutional care, that they regain their independence as soon as possible post discharge. Discharge support generally takes place after discharge from hospital and aims to ease or solve problems after discharge in order to prevent readmissions to hospital or admissions to institutional care and to maximize recovery and improve functional, emotional, social and health status in the post discharge period. A review of these interventions found evidence that some interventions may have a positive impact, particularly those with educational components and those that combine pre-discharge and post-discharge interventions (Mistiaen et al 2006).
Increased communication and cooperation between hospital authorities and local authorities could also help to prevent or mitigate problems associated with hospital discharge. There is significant developmental work ongoing in the homeless and disability sectors which can inform process of enhanced communication and cooperation.
Arranging for occupational therapy assessment of individual needs and their home could also ensure availability of aids to promote independence. Rehabilitation services may enhance an individual's skills to live independently at home and to avoid falls. Some private insurance companies cover private rehabilitation for max of 2 weeks.
Earlier and more efficient discharge planning with targeted dates for discharge could ensure that home adaptations are embarked upon sooner and take into account the expected length of hospital stay. Lessons can be learned, for instance, from advances that have been made in the homeless sector where mental health facilities and prisons are communicating with local authorities in accordance with the National Homeless Strategy to establish protocols and arrangements to engage in pre-planning for the integrated provision of housing and care to homeless people. Similarly, the National Housing Strategy for Disability, due to be published at the end of 2009, is focusing on the interaction of public agencies in addressing the housing needs of people with a disability. While the overall strategic assessment is carried out by the local authority, individual needs are addressed on an individual basis with contact with all relevant agencies and service providers. The new Strategy for Sheltered Housing will also develop this interagency cooperation in the area of hospital discharge to continuing care settings and will be published at the end of 2009.
Community Intervention Teams could also be further developed, as envisaged by Towards 2016, to assist in preventing avoidable hospital admission and the facilitation of early discharge from hospitals, operating in addition to existing mainstream community services to address issues such as capacity to fast-track non-medical care or supports for an interim period, while mainstream services are being arranged for the patient (Towards 2016: 66).
Finally, the development of alternatives to acute care, such as the introduction of additional rehabilitation and continuing care beds, could be an option to mitigate against the issue of the delayed discharge of older people. The 2001 Health Strategy stated that there was a need for the introduction of 5,600 step-down beds over a period of seven years. This has not happened. Obviously, there would be significant resource implications associated with implementation.
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