Multiple Perceptions of Discharge Planning in One Urban Hospital

Since the advent of diagnosis-related groups (DRGs), elderly patients are discharged from hospitals "quicker and sicker." Advocacy groups have claimed that although hospital discharge planners perceive the discharge planning process as helpful, patients and their families do not. In fact, the social process of transferring patients from hospital to posthospital settings has received little systematic study. Participants' perceptions of the process have been studied even less. This study sought to answer two questions: (1) How do discharge planners and family caregivers perceive their influence and the amount and adequacy of information, choice, and time in the discharge planning decision? (2) How do their perceptions differ and agree? Respondents' comments raise important issues that need to be considered in practice and public policy. LITERATURE REVIEW Studies on decision making in discharge planning have investigated patient participation (Coulton, Dunkle, Chow, Haug, & Vielhaber, 1988; Coulton, Dunkle, Goode, & MacKintosh, 1982) and social workers' perceptions of patient participation (Abrahamson, 1988). To date, no studies have conceptualized discharge planning as a social process of small-group decision making by elderly patients, family caregivers, and discharge planners. Participants' perceptions of the process are unknown. Three strategies for understanding the discharge planning process have been identified: (1) use of sociodemographic variables in measuring client characteristics and utilization of helping services (Asser, 1978; Kleinman, 1973), (2) examination of discharge planning and decision-making processes (Abrahamson, 1988; Coulton et al., 1982, 1988; Wetle, Levkoff, Cwikel, & Rosen, 1988), and (3) exploration of organizational responses to clients (Lefton & Rosengren, 1971; Pruitt, 1981). Some investigators have found that the amount and adequacy of information, choice, time, and patient and caregiver influence in decision making during discharge planning may be insufficient (Abrahamson, 1988; Blazyk & Canavan, 1986; Coulton et al., 1982, 1988; Wetle et al., 1988). Indeed, participants involved in health care decisions may perceive the same process quite differently (Wetle et al., 1988). Adequate information about posthospital care options, adequate time to make a decision, perceived choice of options, and influence in the decision enable patients to participate in the discharge planning process and cope with outcomes (Abrahamson, 1988; Coulton et al., 1982, 1988; Wetle et al., 1988). METHOD Setting The sample was drawn from one 450-bed tertiary-care teaching hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations and affiliated with two medical schools. Although the hospital was located in an urban area, the service area was predominantly suburban. Polish, German, Italian, Russian, French Canadian, Jewish, and Irish ethnic groups, as well as black and Hispanic groups, were represented in the towns served by the hospital. The population was predominantly middle, lower-middle, and working class. Sample Data were collected from 40 hospital discharge planners and 40 family caregivers. The study was originally designed to sample planners, caregivers, and hospitalized elderly patients, but the hospital denied approval to interview the patients. High-risk elderly patients - those who were older than 70; living alone; or being treated for hip fracture, cardiovascular disease, stroke, cancer, or other serious condition - were identified for discharge planning by a computerized screening procedure. These patients were considered to be at risk for unmet posthospital needs and rapid readmission to the hospital without planning. Patients assessed as needing nursing home placement by physicians, hospital staff, or family were referred to the social work department; patients expected to return home with services were referred to the nurses in the home care department. …