Discharge Planners Plan? Implications for Older Medicare Patients

What Do

Robbyn R. Wacker University of Northern Colorado Mary A. Kundrat Pat M. Keith Iowa State University

This research examines the discharge-planning process, specifically assessing the extent to which components critical to effective discharge planning are implemented in acute-care settings. We surveyed 16 discharge planners in rural and metropolitan hospitals. The analysis examined the degree to which discharge-planning programs incorporate client-centered planning activities, collect information about the client’s care deficits, use community services to support the client on discharge, and the extent of interdepartment involvement in discharge planning. Results indicated that the majority of planners were client centered in their planning ; however, a complete assessment of the client’s resources and care deficits did not occur on admission. We discuss implications for discharge planning.

Discharge planning is a mechanism that anticipates patients’ needs after institutionalization and sets in place, prior to discharge, methods to address on-going care needs and preserve patient independence. The dischargeplanning process is essential for a smooth transition from a hospital to any less acute setting, including home. Although health care professionals from all disciplines are taught that &dquo;discharge begins with admission,&dquo; it is uncertain whether or not planners are able to implement such directives in the current context of shorter hospital stays and increased pressures for quicker discharges. The discharge-planning process is of particular concern for elderly patients. The elderly are the fastest growing segment of our population and the largest consumers of health services (Dubler, 1988). According to the National Center for Health Statistics (1987), persons over 65 accounted for 30% of all hospital discharges and 41% of all short-stay hospital days of care. As The Journal of Applied Gerontology, Vol. 10 No. 2, June 1991197-207 @ 1991 The Southern Gerontological Society

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continues to decline (Hoffman, 1985), the discharge-planning process becomes increasingly important, especially in rural areas where postdischarge services may be limited. The purpose of this research is to identify the extent to which hospital discharge-planning programs incorporate important elements of the planning process for Medicare clients. the

length

of

hospital stays

Concepts of Discharge Planning Discharge planning is defined as a process that enables the client to choose those services that best assist his or her movement toward independence. Discharge planning is essential and should occur in any service environment. It can begin prior to acquisition of services and extend far beyond the actual discharge. Most important, discharge planning is most effective when it is client centered and client directed. Lack of client participation in discharge planning often results in the clients having little investment in the plan and being angry about others usurping their right to make decisions (Dubler, 1988; Edel, 1985; Lipp, 1977). By others taking posthospital decisions upon themselves, the client feels powerless (Johnston, Kurland, & Reisberg, 1984) and independence is compromised. Independence in this context is not perceived as lack of need for health and social services, but rather as the client’s choosing, through the facilitation of the discharge planner, those services that best enable him or her to function as independently as possible. Independence is related to an individual’s self-care functional ability and perceived needs (Joseph, 1980). Independence deficits, also known as self-care deficits, inhibit the client from performing those aspects of daily living functions that he or she could if able. Many methods of delivering discharge planning exist, ranging from models based on the traditional medical model, with an emphasis on illness, to holistic models focusing on all aspects of personal need. Many professionals advocate a broad definition of discharge planning for a very pragmatic reason: Unless an individual’s perceived needs that assist him or her in maintaining or restoring health are addressed, the person will decompensate and require additional and often more restrictive services in the near future. According to Buckwalter (1985), holistic discharge planning centers around four interrelated concepts. First, one of the primary functions of health and social services personnel is to assist the client in movement toward independence. Second, the independence needs of a client can only be defined by the client and his or her significant others. Third, the primary role of health providers involved in discharge planning is to present options, identify services, and discuss alternatives with the client. Finally, profession-

199

als

charged with facilitating arrangements for the client and providing follow-up to assure that the needs of the client are actually being met by the are

services.

Discharge Planning Framework To effectively function, the discharge planner must assess not only the self-care deficits of the client but have a sound understanding of the motivational aspects that facilitate or discourage the client from using services. The planner must have a thorough understanding of available services and methods of accessing each one. The planner should also understand the client’s resources and support mechanisms that affect the discharge options. Finally, the discharge planner represents not only his or her profession but is the focal point of all health care providers participating in the client’s care. The planner coordinates information from many disciplines and serves as the liaison through which the client is presented with methods to attain or maintain independence after discharge. Because of the planner’s unique knowledge of the client and his or her resources and goals, the discharge planner can also coordinate formal and informal resources in such a way as to provide creative options to meet self-care deficits (White & Simmons, 1988). To maximize resources and effect successful transitions from health care settings in a timely fashion, the discharge planning needs to begin early in a client’s stay (Williams, 1984). All members of the care team need to be involved (Buckwalter, 1985), and a thorough assessment must be compiled (Besdene, 1988; Hughes, 1989; Simmons, 1986; Wetle, 1988). The ability to implement the discharge process in an effective, timely manner depends in part on the training that planners receive. Such training should include those elements of discharge planning previously discussed as well as the availability of posthospital support services. Because the changing financial reimbursement mechanism has resulted in quick movement through the health care system (Hoffman, 1985; Light, 1986), it is important that planners have the autonomy to initiate care plans as soon as possible. The current research examines the discharge-planning process, specifically assessing the extent to which components critical to holistic discharge planning are implemented in acute-care settings. The components included in this analysis are the degree to which discharge-planning programs incorporate client-centered planning activities, the information collected about the clients that is important in developing a comprehensive posthospital plan, the use of community services that provide support services to the client once he or she is discharged, and organizational characteristics, such as interdepart-

200

mental involvement, training of those responsible for discharge planning, and the degree of autonomy that planners have in preparing the discharge plan.

Methodology

Sample Sixteen hospitals in a midwestem state were selected for study. These facilities represented all nonveteran hospitals in an eight-county area. Each facility was contacted by phone to explain the purpose of the survey and to obtain a promise to participate. The survey was mailed to the designated discharge planner in each of the 16 hospitals. All surveys were returned. The 16 facilitiesvaried in size and composition with total bed size ranging from 35 to 1,700 (X= 339; SD = 269). Three facilities had no acute beds and the remainder had 21 to 902 acute beds. Four facilities had skilled beds and one had respite beds available. The number of discharge planners in each facility ranged from 1 to 32. Demographic characteristics of the respondents revealed that most were female (75%) and under the age of 45 (69%). Six had either a Master of Social Work or Master of Science degree, four had education beyond the Masters level, three were registered nurses, and three had Bachelor of Art degrees.

Measures To assess the degree to which hospitals implemented a discharge-planning process, respondents were asked about the characteristics of their planning program. Client-centered planning was measured by two questions: the frequency of mutual goal-setting with the patient for care after discharge always (3) to never (0) - and the frequency with which patients are provided information about alternative care plans - always (3) to never (0). To determine whether the discharge-planning process extended beyond discharge, follow-up on patients after discharge by planners was assessed - almost always (4) to seldom (0). Respondents were asked if and when during the discharge process, seven personal assessment items deemed critical to developing appropriate discharge plans were collected - day of admission (4), one day or more prior to discharge (3), day of discharge (2), varies (1), and not collected (0). These seven items were family’s or caregiver’s capacity to provide care, psychological status of the patient, patient’s perception of health status and needs, patient’s self-care deficits, patient’s expectations for discharge, plan for care

201

after

discharge, and other supportive resources available for posthospital The seven personal assessment items were then recoded into collected on admission (1) and collected after admission (0) and summed to obtain an overall measure of information collected on admission. Awareness and use of a variety of community resources were also measured. Respondents were asked how often planners coordinate posthospital services with 21 community (nonhospital) programs such as Meals on Wheels, home health services, hospice, adult day care, and legal servicescoordination on a regular basis (1) and coordination only occasionally (0). Awareness of the various programs was separately coded - unaware (0) and care.

aware

(1).

The organizational characteristics of the discharge program were also assessed. This included the frequency of involvement in the dischargeplanning process by various individuals, such as the patient, family, physician, and clergy and departments within the facility, such as social services, nursing, dietary, and physical therapy-always (3), often (2), occasionally (1), and never (0); the degree of autonomy that planners have to develop a postdischarge plan without physician’s orders - always (3) and never (0); periodic training of planners-always (3) and never (0); and prior notification of discharge date - always (3) and never (0). Because of the small sample size, the extent to which hospitals employed a patient-centered, holistic approach to discharge planning was examined by descriptive statistical procedures.

Results Half (n = 8) of the organizations’ planning processes include the patient in mutual goal-setting in the discharge process; the remainder of the respondents do so either often (38%, n = 6) or occasionally (12%, n = 2). Over half of the respondents responded that they always provided information about alternative care plans (63%; X = 2.63). Even though the majority indicated that they provided information on alternative care, only 18% (n = 2) of the respondents indicated that they provided follow-up contact with Medicare patients after discharge most of the time or always. The sometimes and seldom categories accounted for 69% (n = 11). Of the seven personal assessment items deemed to be important in the discharge-planning process, family/caregiver’s capacity to provide care and the psychological status of the patient were the only items for which some did not collect information (see Table 1). Patients’ self-care deficits and psychological status were collected on admission by half of the discharge-

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203

Table 2.

Coordination With

Community Services for Posthospital Care

planning programs. The majority of the programs collected information on patient’s expectations for discharge, plans for care after discharge, and the availability of other support resources one day or more prior to discharge. All seven of the personal assessment items were recoded into collected on admission or after (1, 0) and summed to obtain an overall measure of assessments performed on admission. Only four facilities collected all seven assessment items on admission (X 2.18; table not shown). The coordination with and knowledge of community services to assist with postdischarge care by discharge planners is presented in Table 2. Those services providing medical support had a high degree of coordination and awareness. Social support services had low coordination rates. Respondents were more likely to report being unaware of social support services. We report interdepartmental involvement in discharge planning in Table 3. The majority of hospitals reported that they did not have a standing dischargeplanning committee (56%). =

204

Table 3.

Degree of Individual/Department Involvement in the Discharge Planning Process

NOTE: Totals do not equal 16 because of nonresponses.

Timely referral by physicians and nurses of patients for postdischarge planning and discharge-planner training and autonomy to initiate care plans are reported in Table 4.

Summary The

majority of respondents indicated that their discharge-planning proalways client centered; however, a complete assessment of the

was

gram client’s

resources

and

care

deficits did not

occur

in the earliest stage of the

hospital stay-on admission. The discharge-planning literature emphasizes the importance of client and family involvement as the core component in successful posthospital care (Hochbaum & Galkin, 1987; Merritt, 1989). Lack of self-determination in deciding placement increases client frustration and inhibits independence. Early initiation of discharge plans allows for greater family and service participation as well as for necessary multidisciplinary referrals (Nice, 1989). A more holistic focus can be achieved by engaging the discharge-planning process early in a client’s hospitalization. This focus is of a particular importance for the elderly client who frequently has fewer resources and greater support needs (Hochbaum & Galkin, 1987). Follow-up to determine if the postdischarge plans were meeting the needs of the clients was not a part of the discharge process in a majority of facilities. For these organizations, the discharge planning process seemed constricted

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