Comprehensive

Discharge Planning

&
Evidence Based Practice
Presented by: Jennifer R. Williams R.N.

What does the literature reveal about the utilization and effectiveness of discharge planning and the ethics associated with the process?

Discussion Points

What the Evidence Presents Analysis of the Evidence

Discussion and Experience

Recommendations Overall Conclusion

What does the evidence present?

Discharge planning is an essential part of the discharge process. Discharge planning is an integral process in acute care. Comprehensive discharge planning improves the outcomes of patients post discharge. Discharge planning often lacks instruction on psychological and social issues.

Evidence cont

Having a designated discharge planner or care manager, improves the discharge process. It is important to incorporate all disciplines into the planning process. Nurses are often not oriented appropriately in discharge planning. Managed care puts limits and constraints on nurses, causing ethical dilemmas with discharge plans.

Analysis of the Evidence

Research on Comprehensive Discharge Planning of the Hospitalized Elderly

Problem

To study the effects of a comprehensive discharge planning protocol.

Content of Research

There were 276 patients and 125 caregivers included in study. Patients were 70 years and older and alert and oriented at time of discharge. Patients separated into four groups: Medical control group, Surgical control group, Medical intervention group, and Surgical intervention group. Patients were randomly assigned to intervention and control groups. Medical diagnoses included: Congestive heart failure and Myocardial infarction/Angina. Surgical diagnoses include: Coronary bypass graft and cardiac valve replacement. Nurse specialists with masters degrees in gerontology nursing and a minimum of 1 year of practice implemented the designed protocol for the intervention groups. Standard discharge planning process utilized in the control groups.

Data Collection

Comprehensive physical assessments and interview of patients at two, six, and twelve weeks post discharge. Documentation of re-hospitalization for both control and intervention groups. Calculation and cost comparison of re-hospitalizations versus specialized in home care as initiated with the comprehensive discharge program.

Results

Patients in the medical and surgical intervention groups had fewer readmissions, fewer total days re-hospitalized, lower readmission charges, and lower charges for out patient health care services post discharge.

Interventions Affecting Research Outcomes

Comprehensive initial and ongoing assessment of the discharge planning needs of the patient and his or her caregiver. Development of a discharge plan with inclusion of all disciplines involved with patients care. Improved and validated education of patient and caregiver. Early initiation of discharge planning during hospitalization and continuation of plan through two weeks post-discharge. Improved interdisciplinary communication regarding patients discharge status. Ongoing evaluation of the effectiveness of the discharge plan during and after discharge.

Limitations of Research

Study performed in an urban setting. Most patients were well educated with good support systems and minimal functional deficits.

Further Study Recommendations

Study should be replicated with elderly patients admitted from various settings, including nursing home. Study should include patients with cognitive and functional deficits and limited support systems. Additional diagnosis along with various geographical areas should also be included in future studies.

Analysis of the Research Findings

Comprehensive discharge planning improved outcome of patients. Improved intervention = More cost effective. Interdisciplinary cooperation assists in improved discharge plan. Intensive follow up after discharge needed to improve patient outcomes.

Conclusion

Implementing a comprehensive discharge plan early in a patients hospitalization, including needed disciplines in the process, and increased utilization of follow up services after discharge improves patients long term outcomes and decreases medical costs.

Research on Discharge Planning as Part of the Daily Nursing Process

Problem

Discharge planning efforts within increasingly focused environments and competing priorities.

Content of Research

Study conducted in 32-bed surgical unit. Seven women undergoing total abdominal hysterectomies were included in the study. Patients ages ranged from 36-70 years. Eight RNs working full or part time were also included in the study. Nurses ages ranged from 22-37 years with professional experience of 1 month to 17 years with at least an associate nursing degree.

Data Collection

Participant observation conducted to capture nursepatient interaction and unit activities. Informal and formal interviews conducted with all of the informants. Review of all relevant unit resources and polices along with patients medical records.

Results

Deficits were found in both documentation of discharge planning implementation as well as nursing reliance on the typical patient for guidelines of the discharge plan.

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Problems Affecting Adequate planning

Nurses under time constraints. Nurses focused on physical recovery and not psychosocial or social needs. Discharge plan not personalized to patients. Bulk of planning performed on the day of discharge. Discharge planning that was completed was not documented appropriately.

Research Limitations

Use of a small population of both patients and nurses. Data collected on day shift only. Gender of patients were all female. Variable patient-nursing assignments disrupted continuity of care.

Analysis of Research Findings

Patient assignments interfere with proper and comprehensive discharge planning. Appropriate documentation is difficult to complete under time constraints. Poor outcomes of patients focuses on the need for coordination of care. Discharge planning is a complex and nursing-intensive work and needs to be recognized as such.

Conclusion

Recognition of discharge planning as a complex and nursing-intensive work is imperative in the attempt to incorporate this process into day to day nursing or to convince organizations of the need for a designated discharge planner.

Research on Ethical Dilemmas Among Nurses as They Transition to Hospital Case Management. Part 1&2

Problem

The exploration of ethical concerns of clinical nurses as they transition into hospital case management.

Content of Research

Fifteen nurse case managers were included in the study. Subjects were collected from acute hospitals, military hospitals, non-profit hospitals, and teaching hospitals. Subjects were involved in either discharge planning, case management, or utilization review activities.

Data Collection

Each nurse was interviewed. In-depth interviews averaging 11.5 hours were utilized. Interviews were audio taped then transcribed. Data was interpreted using Max van Manens method of thematic analysis.

Results

In adequate orientation to case management for beginning case managers. Obligations to organization affects ability to advocate for patients. Managed care often affects adequate and thorough discharge planning.

Ethical Issues Identified in Findings

Organization instruction affects initiating appropriate services for patient realities. Insurance policies and need for cost containment decrease the planners ability to provide advocacy, autonomy, and appropriate patient needs at discharge. Perceived inadequate planning and organizational funding affects proper orientation and education of case managers.

Research Limitations

Study limited to 15 participants. Performed only in the midAtlantic region of the United States. Not all health care settings utilized. Ethical dilemma research limited to case management process.

Further Study Recommendations

Include more geographical areas. Investigate additional health care settings to include emergency, home health, hospice, etc.. Include different ethnic backgrounds of patients cared for by the case managers.

Analysis of Research

Nurse case managers experience frequent ethical concerns. Rules and regulations often conflict with nurses own professional judgment. Limited knowledge affects appropriate quality nurse management. Case managers have difficulties overcoming obstacles affecting their obligations to patients. Policy change and system reform may be needed to overcome difficulties with patient advocacy.

Conclusion

The conflicts in values related to patient safety, advocacy, and professional opinion is a difficult ethical battle that case managers often encounter. Lack of organizational resources leave discharge planners distressed, helpless, powerless, and frustrated. Lack of appropriate orientation in combination with ethical concerns can cause a lack of adequate patient plans during hospitalization and post discharge, making many case managers uncomfortable with the decisions they make.

Discussion and Experience

Lets Discuss

The difficulties nurses often face focusing on patients and discharge needs. The lack of appropriate discharge planning that is common in hospitals without a designated discharge planning department. The incorporation of other disciplines into discharge planning. The ethical issues that play a large role in the discharge planners ability to plan appropriately for the patient. The researches expression that discharge planning is an essential part of the discharge process despite frequent poor construction.

My Personal Experience and Observation as a Discharge Planner and Continuing Care Coordinator

Personal Experience

I have been involved with discharge planning for two years. I am an RN currently preparing for my BSN degree. I have been a nurse for almost ten years and have worked in multiple areas of nursing.

Difficulties That I Often Encounter in Discharge Planning

As a discharge planner it is my job to educate, facilitate, communicate, and integrate information appropriately to complete a personalized discharge plan for each patient. Taking the time to get individuals to discuss their issues is a very important factor, although often time consuming and difficult. It is challenging at times to deal with uncooperative and noncompliant patients or families. It is often a struggle in my position to manage the cooperation of all disciplines involved in a patients care.

Difficulties cont

Managed care and budget constraints often put a limit on the abilities I have as a discharge planner. I often struggle with the short hospital stays and time constraints put on me during the planning process. Lack of funding at the facility, in which I work, makes it difficult to stay updated on current discharge planning practices. It is important for me to do my best both professionally and ethically to plan for the best possible outcomes for my patients.

Recommendations for Evidenced Based Practice

Implementation of comprehensive discharge planning is supported in this research. Health care organizations should h designated a nurse discharge planner or department. Existing discharge planning areas should be evaluated for effectiveness.

Suggestions for New Planning Implementations

Inclusion of all disciplines during planning process with a suggestion for implementation of daily multidisciplinary meetings and recording of the findings. Improved education for families and patients with early introduction of discharge planning and support of the plan from all disciplines. Improved orientation, education, and continuing education programs for discharge planners and case managers.

Conclusion of Research Evidence and Use in Evidenced Based Practice

The literature reveals that discharge planning is not always an effective process. Managed care, time constraints, short stay hospitalization, and ethical issues all contribute to discharge planning issues. Implementation of this evidence based practice into the field of discharge planning would be successful in improving patient outcomes and the reputation of this important process.

References
Foust, J.B. (2007). Discharge planning as part of daily nursing practice. Applied Nursing Research, 20, 72-77. Retrieved on June 14, 2009 from Ferris Flite Library. Kasinskas, C., Koch, M., Wood, R. (2009). Factors influencing physical therapy discharge planning in the acute care setting. Acute Care Perspectives. Retrieved July 15, 2009 from www.thefreelibrary.com/. OBrien, B. (2001). Review: evidence of the effectiveness of discharge planning is equivocal. Evidenced Based Medicine, 6(4), 123. Retrieved July 17, 2009 from ebm.bmj.com. ODonnell, L.T. (2007) Ethical Dilemmas Among Nurses as They Transition to Hospital Case Management. Implications for Organizational Ethics, Part 1 & 2. Professional Case Management, 12(3), 160-169. Retrieved July 7, 2009 from Ferris Flite Library. ODonnell, L.T. (2007) Ethical Dilemmas Among Nurses as They Transition to Hospital Case Management. Implications for Organizational Ethics, Part 1 & 2. Professional Case Management, 12(4), 219-231. Retrieved July 7, 2009 from Ferris Flite Library. Maramba, P.L. (2004). Discharge Planning Process. Applying a Model for Evidence-based Practice. Journal of Nursing Care Quality, 19(2), 123-129. Retrieved July 10, 2009 from Ferris Flite Library. Naylor, M., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey, M., Puly, M. (2004). Comprehensive Discharge Planning for the Hospitalized Elderly. A Randomized clinical Trial. Annals of Internal Medicine, 120(12), 9991006. Retrieved July 7, 2009 from www.annals.org/cgi/content/full/120/12/999