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Hospital Discharge for Frail Older People: A Literature Review with Practice Case Studies - Research Findings

DescriptionThis study identified and examined recent literature relating to the discharge of frail older people.
Official Print Publication Date
Website Publication DateJanuary 27, 1999
Social Work Research Findings No. 24 (1998)
Hospital Discharge for Frail Older People: A Literature Review with Practice Case Studies

Patricia Taraborrelli, Fiona Wood, Andrew Pithouse, Michael Bloor and Odette Parry

ISBN 0-7480-7161-XPublisher The Scottish OfficePrice £5.00
This study identified and examined recent literature relating to the discharge of frail older people and assessed the contribution of that literature to current practice. There were two main aspects to the study: an extensive review of the existing literature; and a review of case studies of discharge practice at four Scottish NHS Trusts, selected to represent a range of circumstances and catchment area populations.
Main Findings
  • There is a consensus in the literature that appropriate discharge requires: a period of preparation; adequate notice of discharge to the concerned parties; discussion of after-care arrangements with users and carers; liaison with community care professionals; education of users and/or carers; a comprehensive and effective system of information collection and dissemination between hospital and community; and co-ordination by a skilled and knowledgeable 'named nurse.'
  • There is a need for rigorous evaluative studies to be undertaken of different innovative discharge schemes. Other areas requiring further research effort are: qualitative studies of social processes and practical constraints on discharge decision making; and health economics research with cost/benefits analysis of different discharge arrangements.
  • The case studies revealed a diversity of discharge arrangements reflecting diversity in the needs of frail older users, hospital case mix and local differences in the pace of development of discharge policies.
  • A number of innovative discharge arrangements were apparent in the case studies involving practices such as joint documentation, early or supported discharge schemes and discharge liaison nurses or health visitors.
  • At present, hospital discharge is too frequently characterised by clashing professional perspectives: social workers, nurses and clinicians often have conflicting views. Representatives from the housing and voluntary sector tend to be left out of the decision making process. Liaison between community and hospital continues to cause problems.
  • Hospital discharge policies appear to be influenced more by national policy guidelines than research findings.
Recent developments in health and social care arrangements, such as the 1990 NHS and Community Care Act, the shift from acute to primary care and the decline in the length of hospital stays, have all focused public attention on the adequacy of hospital discharge arrangements for frail older people. Issues that have received particular attention have been assessments, notice of discharge, involvement of users and carers, and inter-professional communication and planning.
There is a substantial amount of literature relating to the discharge of older people from hospital. However, no previous studies have examined to what extent the literature has contributed to the development of discharge policies and procedures. The aim of this research was to assess the actual and potential contribution of current research to discharge practices for this user group and identify gaps where further research was required.
The literature review entailed an extensive search of British literature and a more limited search of European material. Documents and guidelines were also obtained from a number of academic, professional, statutory and voluntary organisations.
Policy and protocol documents were gathered from four NHS Trusts in Scotland. The documentation that was collected ranged from general policy statements, to assessment forms and check list planners for individual wards, and leaflets provided for patients and carers. Across the four Trusts, a range of acute, assessment, rehabilitation and psychogeriatric wards were selected and became the focus of the case studies. Documentation was also collected from social work and housing departments. The Trusts' documentation was systematically compared with published 1993 NHS Scotland guidelines.
The four selected trusts were visited and 30 interviews were conducted with a range of professionals working in the health, social care, housing and voluntary sectors. It should be stressed that the case study findings are based on documentation and interview reports, rather than on observed practice.
The literature
The research literature incorporated a range of methodologies ranging from surveys of staff and patients, focus groups, case studies, interviews and analysis of patient records. The extent of the research literature reflects the view that discharge planning should begin before and extend beyond the hospital ward.
Research in this field covers topics such as pre-admission planning, patient assessment, provision of services and referrals, follow up and evaluation. It is essential that admission protocols provide for the screening of patients requiring community care assessment. The literature reveals that discharge assessment practice varies greatly in extensiveness and in the numbers of professional disciplines involved. Limited use is made of validated scales measuring functional and mental capacities which can impact on the quality of discharge assessments and outcomes.
Research also exists on: the experiences of users; sources of tension between agencies; the assessment of risk; documentation and communication; medication and health education; and the role of the voluntary sector. The mechanisms and quality of communication between hospital and community based professionals remains a concern. Discharge liaison nurses are reported to facilitate earlier discharge, improve after-care and reduce readmission rates, but can only be a partial solution to the complexities of hospital discharge. GPs value receiving direct and informative discharge summaries on the same day as their patient's discharge.
Professionally-led supported discharge schemes are thought to be highly cost-effective, but suitable users must be adequately screened. Voluntary discharge schemes (using both paid and volunteer staff) are thought to be a valuable complement to statutory provision, but not a replacement for such provision. Sometimes such schemes were inadequately geared to GP services and the work of nurses and home helps.
Overall, the review found that the literature lacks direction and rigour and is characterised by: an absence of suitable control populations for comparison; small sample sizes; a lack of cost-benefit analyses; an absence of valid, reliable outcome measures for a "successful discharge"; and the absence of good qualitative studies of discharge decision making.
The case studies
The case studies revealed that all four NHS Trusts had a high level of commitment to good practice for discharge of frail older people. Some note-worthy practices are being used such as joint documentation between health and social care, discharge liaison nurses and supported discharge schemes. Some areas of good practice were not covered by all of the four Trusts' policies and some Trust documentation requires updating in the light of recent guidance and literature. In particular, aspects such as pre-admission planning, and the provision of advice to patients and carers on how to contact support groups, were often absent from the Trusts' documentation but are explicit in the 1993 NHS Scotland guidelines.
Furthermore, from the interview data it appears that not all of the Trusts' policy documentation was being implemented in practice resulting in a number of problems in the discharge process. Problems were associated with the relationship between health care and social care professionals. The limited involvement of the housing and voluntary sector was also a cause for concern. Problems surrounding multi-agency working may in part be explained by: poor communication and sharing of information; poor recognition of the role and expertise of other professional groups; funding problems; shortages of suitable nursing or residential accommodation; and differing perceptions of risk.
There is some element of duplication of effort particularly between occupational therapy and social work assessments. All of the four trusts were using discharge checklists, but other monitoring arrangements were variable in terms of Quality Standards, generation of information of standards achievement and review procedures. Two of the trusts were in the process of revising their discharge policy documentation. A third trust had different discharge documentation for each ward. However, this could be interpreted as a strength given that frail older users are likely to differ in their discharge needs and problems according to the nature of their medical condition.
Hospital discharge practices for frail older people differ between Trusts depending on local needs and case mix. Consequently no one panacea exists but rather there are a range of good practices. This allows the selection of the most appropriate models for local needs.
Practice is determined more by policy than research. The most important influence on local practice are the published 1993 NHS Scotland guidelines. This review only examined the policies and practices of four trusts, it maybe that there are other trusts whose practices and policies are more firmly grounded in the research literature. If research influences hospital discharge practice then it is likely that this is largely indirect through the medium of published guidelines.
Published guidelines are also occasionally at odds with research evidence. For example, Scottish Office guidelines recommend GPs to be informed of discharge via the patient, whereas research literature stresses the need for GPs to be informed via the hospital by phone or fax.
There are also a number of areas where research in hospital discharge has so far been limited, such as: evaluation of pre-admission planning and patient screening schemes; evaluation of self medication schemes, "Going Home" folders and other written information for patients and carers; and the identification of appropriate user characteristics for the range of different discharge-related schemes such as the "Hospital at Home" and discharge liaison nurses.
There is a need for further research into the development of a measure of a "successful discharge", instead of the current over-reliance on re-admission rates as a measure. There is also a need for rigorous evaluative studies of different discharge schemes. Other areas requiring further research effort are qualitative studies of social processes and practical constraints on discharge decision making and health economics research with cost/benefits analysis of different discharge arrangements.
Research should be undertaken within multi-disciplinary research teams so that ownership of the research is multi-disciplinary and therefore more likely to be acted upon by all the professions.
The study was carried out by the School of Social and Administrative Studies, University of Wales, Cardiff. It was funded by the Social Work Services Group of The Scottish Office.
'Hospital Discharge for Frail Older People', the research report summarised in this Research Findings, may be purchased (price £5.00 per copy).
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