Comprehensive Discharge Planning for the Hospitalized Elderly

More than 10 million Medicare beneficiaries were discharged from hospitals in 1990 [1]. This number is expected to increase substantially over the next few decades. The average hospital stay for an elderly patient in 1991 (8.5 days) was approximately 1.8 days shorter than that in 1981, an 18% reduction [2]. Although no evidence suggests that earlier hospital discharge harms the health of elderly patients, little doubt exists that their care after discharge places a difficult burden on families and the health care system [3, 4]. A national study of the effect of the Prospective Payment System indicated that the number of elderly patients discharged in unstable conditions has increased across the board rather than in any specific patient or hospital subgroup [5]. Additional research findings suggest that some elderly patients discharged from hospitals may require care too complex for families to manage alone [6-8]. Earlier hospital discharge has been associated with substantial growth in the number and breadth of services available after discharge for Medicare beneficiaries, including emergency room visits, acute care visits to physicians, and home visits by registered nurses [2, 9]. Despite efforts to control costs, home health care expenditures for elderly patients increased 583% from 1980 to 1991 [2]. Rehospitalizations of Medicare beneficiaries currently account for at least one quarter of all hospital admissions [10-12]. As a public program and the largest single payer for health care, Medicare plays a central role in the current health care debate. It is an obvious target for major budget savings. Increasing pressure to contain costs further raises serious concerns about the continued access of elderly patients to the care they need and the quality of that care [13]. A critical need exists for interventions that facilitate the discharge of elderly patients to their homes, that prevent poor outcomes after discharge, and that reduce health care costs. Effective discharge planning can facilitate the timely discharge of elderly patients and ensure that appropriate care is available in the home to prevent readmissions, to lessen the burden of care on families, and to reduce costs [14]. The elderly need quality discharge planning because, at any given time, they occupy more than 34% of hospital beds, are substantial users of services after discharge, and are at high risk for poor outcomes after discharge [1, 6, 15]. Unfortunately, a national panel of experts rated the quality of discharge planning available for this group as very poor [16]. Several approaches to improve discharge planning for elderly patients have recently been tested [17-19]. Our study, an adaptation of a discharge planning and home follow-up program by nurse specialists [20], also builds on an earlier study of the effects of a discharge planning protocol developed for the elderly [17, 21]. The purpose of our study was to determine the effects of a comprehensive discharge planning protocol designed specifically for the elderly and implemented by nurse specialists on patient and caregiver outcomes and charges for care. Methods Study Sample Eligible patients were 70 years and older, were admitted from their homes to the Hospital of the University of Pennsylvania, and were from selected medical and surgical diagnostic-related groups (DRGs). Patients were randomly assigned to an intervention or control group. The medical DRGs were congestive heart failure and angina/myocardial infarction. Surgical DRGs were coronary artery bypass graft and cardiac valve replacement. In addition, patients had to speak English, be alert and oriented when admitted, and be able to be reached by telephone after discharge. Caregivers, persons identified by patients as those who would assume primary responsibility for their care after discharge, were also enrolled. Patients who did not identify a caregiver were included in the study. Control Group Patients in the control group received the hospital's routine discharge plan, which is used for patients of all ages and diagnostic classifications. Criteria-based screening of all hospital admissions normally occurred within 48 hours of admission. Uncomplicated discharges were managed by the patient's physician and primary nurse. Complicated discharges, which necessitated coordination of services and external providers, involved social workers and community nursing coordinators employed by the hospital. Discharge planning services were provided in accordance with the medical plan of care. Intervention Group Patients and caregivers in the intervention group received the hospital's routine plan and a comprehensive, individualized discharge planning protocol developed specifically for elderly patients and implemented by gerontologic clinical nurse specialists [see Appendix]. The protocol extended from hospital admission to 2 weeks after discharge. Compared with the hospital's routine procedure, the discharge planning protocol included the following unique features: 1) comprehensive initial and ongoing assessment of the discharge planning needs of the elderly patient and his or her caregiver; 2) development of a discharge plan in collaboration with the patient, caregiver, physician, primary nurse, and other members of the health care team; 3) validation of patient and caregiver education; 4) coordination of the discharge plan throughout the patient's hospitalization and through 2 weeks after discharge; 5) interdisciplinary communication regarding discharge status; and 6) ongoing evaluation of the effectiveness of the discharge plan. Two half-time nurse specialists with master's degrees in gerontologic nursing and a minimum of 1 year of practice as a nurse specialist were hired to implement the comprehensive discharge planning protocol for patients in the intervention group. Within 24 to 48 hours of admission, the nurse specialist visited the patient and contacted the caregiver to complete the initial patient and caregiver assessment and to document the preliminary discharge plan. The nurse specialist visited the patient every 48 hours thereafter to implement the plan through patient and caregiver education, referrals, consultation with health care team members, counseling, and coordination of home services. The final visit was made within 24 hours of discharge to finalize discharge preparations. Summaries of the discharge plan were recorded in the patient's chart and distributed to the patient, primary care physician, and other health care team members who would care for the patient at home. In addition to personal visits, the nurse specialist was available 7 days a week by telephone (8 a.m. to 10 p.m. on weekdays; 8 a.m. to 12 p.m. on weekends) throughout the patient's hospitalization and for 2 weeks after discharge for any questions or concerns from the patient, caregiver, or health care team member that were relevant to the discharge plan. The nurse specialist also initiated a minimum of two telephone calls during the first 2 weeks after discharge to monitor the patient's progress and intervene when necessary. Statistical Analysis The chi-square or the Fisher exact test and independent t-tests were completed where appropriate. Ninety-five percent CIS were calculated for differences between means or differences between percentages. All P values are two-tailed. Because all patients had their index hospitalizations at the same site, actual charge data were used to calculate the cost of initial hospitalizations. Patients were readmitted, however, to various large teaching and small community and rural hospitals. Because of the wide range of charges at these settings, rehospitalization charges were calculated using the mean charge per day for the index hospitalizations for the medical DRG group times the actual number of days of subsequent hospitalizations. The total charges for health care services after discharge incurred by patients in our study were calculated for all study groups. These included charges for rehospitalizations; visits by patients to emergency rooms, physicians' offices, or clinics; visits to patients' homes by nurses, allied health professionals, or home health aides; and the services of the nurse specialists (intervention group only). With the exception of readmission charges, actual charge data were used to calculate the cost of health services after discharge. The charges for the nurse specialists' services were based on the time devoted to the discharge planning intervention. The time spent in the direct care of patients and their caregivers (for example, patient education) and indirect care (for example, coordinating services after discharge) was measured and converted to charges using a competitive compensation base (salary plus fringe benefits) for nurse specialists in the same geographic area. Results Of the 364 patients enrolled between July 1989 and February 1992, 36 died (17 patients in the intervention group and 19 patients in the control group) and 52 either changed their minds about participating in the study or were unable to be contacted after discharge. Eighty-one percent of the deaths occurred during the initial hospitalization (n = 22) or the week immediately after discharge (n = 7). Patients in the final study sample (n = 276) and the attrition group (n = 88) were similar respecting all sociodemographic variables except age (P = 0.002) and employment status (P = 0.04). The mean age of patients in the study sample was 75.5 years, compared with a mean age of 77.5 years in patients in the attrition group; in the study sample, 80% of patients were not employed, compared with 90% of patients in the attrition group. The health status of patients in the study and attrition groups was also similar at hospital admission as measured by the Medis Group Severity of Illness scores, the total number of comorbid conditions, the number of prescribed daily medications, and the number of hospital admissions du