One of the most common terms heard in inpatient hospital settings throughout the country currently is “length of stay.” This essentially refers to how long a patient occupies a bed in a hospital. The objective of some hospitals is to minimize the length of stay in an effort to contain costs. Due to most hospitals’ priority of keeping length of stay as short as possible, discharge planning begins upon admission to the hospital. It is a process that capitalizes on social worker’s engagement, assessment, and planning skills.An effective discharge plan ensures that a patient is being discharged to a safe environment that is conducive to healing and recovery. In some cases, this is different from the environment they were living in prior to the hospitalization. In addition, the discharge plan must adequately meet the patient’s medical needs outside of the hospital environment. This can include coordinating follow-up medical appointments and appropriate therapies, ordering medical equipment, arranging home health care, placing the patient in a skilled nursing facility, and linking the patient to supportive community resources. Constructing a discharge plan requires hospital social workers to collaborate with the patient, his or her family, caregivers, medical team, and community resources.To prepare for this Discussion, think about the components of discharge planning and the individuals involved in discharge planning. Consider medical social work practice skills within the generalist intervention model as discussed in Discussion 1 this week. Examine the factors involved in creating a discharge plan for a patient in a hospital setting. Consider the specific roles a medical social worker plays in creating a discharge plan.By Day 4Post a brief description of the components of discharge planning. Identify and explain the key factors that must be considered in the discharge planning process. Explain the roles of a medical social worker in creating a discharge plan. Be specific. Then, explain how discharge planning incorporates all of the practice skills in the generalist intervention model. Finally, explain challenges a medical social worker might face working with other professionals involved in discharge planning.
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Fox et al. BMC Geriatrics 2013, 13:70
http://www.biomedcentral.com/1471-2318/13/70
RESEARCH ARTICLE
Open Access
Effectiveness of early discharge planning in
acutely ill or injured hospitalized older adults:
a systematic review and meta-analysis
Mary T Fox1*, Malini Persaud1, Ilo Maimets2, Dina Brooks3, Kelly O’Brien3 and Deborah Tregunno1
Abstract
Background: Older age and higher acuity are associated with prolonged hospital stays and hospital readmissions.
Early discharge planning may reduce lengths of hospital stay and hospital readmissions; however, its effectiveness
with acutely admitted older adults is unclear.
Methods: In this systematic review, we compared the effectiveness of early discharge planning to usual care in
reducing index length of hospital stay, hospital readmissions, readmission length of hospital stay, and mortality; and
increasing satisfaction with discharge planning and quality of life for older adults admitted to hospital with an
acute illness or injury.
We searched the Cochrane Library, DARE, HTA, NHSEED, ACP, MEDLINE, EMBASE, CINAHL, Proquest Dissertations
and Theses, PubMed, Web of Science, SciSearch, PEDro, Sigma Theta Tau International’s registry of nursing research,
Joanna Briggs Institute, CRISP, OT Seeker, and several internet search engines. Hand-searching was conducted in
four gerontological journals and references of all included studies and previous systematic reviews. Two reviewers
independently extracted data and assessed risk of bias. Data were pooled using a random-effects meta-analysis.
Where meta-analysis was not possible, narrative analysis was performed.
Results: Nine trials with a total of 1736 participants were included. Compared to usual care, early discharge
planning was associated with fewer hospital readmissions within one to twelve months of index hospital discharge
[risk ratio (RR) = 0.78, 95% CI = 0.69 − 0.90]; and lower readmission lengths of hospital stay within three to
twelve months of index hospital discharge [weighted mean difference (WMD) = −2.47, 95% confidence intervals
(CI) = −4.13 − −0.81)]. No differences were found in index length of hospital stay, mortality or satisfaction with
discharge planning. Narrative analysis of four studies indicated that early discharge planning was associated with
greater overall quality of life and the general health domain of quality of life two weeks after index hospital
discharge.
Conclusions: Early discharge planning with acutely admitted older adults improves system level outcomes after
index hospital discharge. Service providers can use these findings to design and implement early discharge
planning for older adults admitted to hospital with an acute illness or injury.
Keywords: Discharge planning, Aged, Length of stay, Hospital readmission, Patient discharge, Systematic review,
Meta-analysis
* Correspondence: maryfox@yorku.ca
1
School of Nursing, York University, 4700 Keele Street, Toronto, Ontario M3J
1P3, Canada
Full list of author information is available at the end of the article
© 2013 Fox et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Fox et al. BMC Geriatrics 2013, 13:70
http://www.biomedcentral.com/1471-2318/13/70
Background
Individuals who present with older age and higher levels
of acuity are at risk for longer hospital stays and hospital
readmission [1]. Prolonged hospital stays and hospital
readmissions are costly to both older adults and the
healthcare system. These events are associated with
increased risk of iatrogenic complications, functional decline, and mortality in older adults [2] as well as
increased hospital expenditures. Older adults account
for 50% of hospital expenditures in Canada [3] and 45%
of hospital expenditures in the United States (US) [4]
despite representing only 14% of the Canadian population [5] and 13% of the US population [6]. With fiscal
restraints and projected increases in age demographics
in several countries, reducing lengths of hospital stay
and hospital readmissions for older adults is a priority
to healthcare service-providers and policy-makers
[7-9]. While Canadian and US healthcare providers
have either adopted or are considering various discharge planning programs [10-13], the overall effect of
discharge planning introduced during the acute phase
of an older person’s illness or injury, is unclear and
unquantified.
Early discharge planning is defined by interventions
initiated during the acute phase of an illness or injury to
facilitate transition of care back to the community as
soon as the acute event is stabilized [14]. Prior reviews
examining the effectiveness of discharge planning in reducing lengths of hospital stay [15-20] and hospital
readmissions [15-20] have several limitations, supporting
the need for this current review. All prior reviews combined data from studies that included younger and older
adults [15-20]. Three of these reviews also combined
data from studies that initiated discharge planning during the acute and post-acute phases of illness or injury
[16,19,20], including at the time of hospital discharge or
later [15,16,20]. The results may not be generalizable to
hospitalized older adults in the acute phase of an illness
or injury.
The objective of this study was to compare the effectiveness of early discharge planning to usual care primarily in reducing index length of hospital stay, hospital
readmissions, and readmission length of hospital stay
and secondarily in reducing mortality and increasing
satisfaction with discharge planning and quality of life
for older adults admitted to hospital with an acute
illness or injury.
Methods
We conducted a systematic review that compared early
discharge planning, initiated during the acute illness or
injury phase, to usual care using the Cochrane Collaboration Protocol [21].
Page 2 of 9
Eligibility criteria
Eligible studies included published and unpublished randomized control and quasi-experimental trials with parallel controls that compared early discharge planning to
usual care for adults aged 65 years and older in the acute
illness or injury phase, defined as “the period during
which an illness or injury is being intensively treated and
stabilized” (p. xii) [22]. Early discharge planning was defined by interventions during the acute phase of illness
or injury to facilitate transition of care back to the community [14]. Usual care was defined as any care in which
discharge planning, if provided, was not identified as
having been initiated early, during the acute phase of illness or injury.
Eligible studies included at least one primary outcome
(index length of hospital stay, hospital readmissions, or
readmission length of hospital stay) or at least one secondary outcome (mortality, satisfaction with discharge
planning, or quality of life). Index length of hospital stay
was defined as the total number of consecutive days in
the study hospital where early discharge planning or
usual care was initiated. Hospital readmissions refer to
the number of patients readmitted one or more times to
an acute care hospital between index hospital discharge
(regardless of discharge destination) and the end of
study follow-up. When study authors defined hospital
readmissions by rehospitalization or death after index
hospital discharge [23] we presumed that patients who
died after index hospital discharge also experienced hospital readmission. Readmission length of hospital stay refers to the mean number of hospital days per patient
from the time of index hospital discharge to the end of
study follow-up. Mortality was defined as the cumulative
number of deaths from index hospital admission to the
end of study follow-up. Satisfaction with discharge planning was defined by the level of satisfaction with discharge planning that included satisfaction with hospital
communication and/or co-ordination and continuity of
care across settings as reported by each of three groups:
older adults, caregivers, and community healthcare providers. Quality of life refers to level of well-being as
reported by each of two groups: older adults and their
caregivers.
Ineligible studies were those that were unavailable in
English or French; compared usual care units to acute
care for elders units (ACE) or geriatric units which provided early discharge planning as one of two or more
ACE intervention components; compared usual care to
exercise programs in which early discharge planning was
provided; included historical control groups; included
patients in the sub-acute or post-acute phase, which
refer to the period “following stabilization of a disease or
injury” (p. xii) [22]; included social admissions; or included patients receiving palliative care or admitted for
Fox et al. BMC Geriatrics 2013, 13:70
http://www.biomedcentral.com/1471-2318/13/70
elective surgical procedures such as arthroplasty. Studies
that initiated the intervention upon or after index hospital discharge, or studies that focused on the provision
of care after index hospital discharge were also excluded.
Search strategy and study selection
The literature search was conducted by an information
specialist with input from team members with expertise
in the clinical area to identify keywords. Keywords included, but were not limited to: discharge planning,
comprehensive discharge planning, early discharge planning, early supported discharge, transition, aftercare, patient care planning, advance care planning, length of
stay, patient readmission, patient transfer, and patient
care management (Additional file 1). Electronic databases searched included: EBM Reviews consisting of the
Cochrane Library, DARE, HTA, NHSEED and ACP;
MEDLINE; EMBASE; CINAHL; Proquest Dissertations
and Theses; PubMed; Web of Science; SciSearch; PEDro;
Sigma Theta Tau International’s registry of nursing research; Joanna Briggs Institute; CRISP; and OT Seeker.
Internet search engines included: Google, Yahoo, Scirus,
Healia, and HON. Hand-searching was conducted in
The Gerontologist, Age and Ageing, Journal of the
American Medical Association, Journal of the American
Geriatrics Society, and bibliographies of all included
studies and previous systematic reviews. We also searched
for specific programs including Care Transitions, Transitional Care, Project BOOST Society of Hospital Medicine,
Re-engineered Discharge and Transforming Care at the
Bedside in EBM Reviews; MEDLINE; EMBASE; CINAHL;
PubMed; and Web of Science (Additional file 2).
Teams of two reviewers from the group of investigators independently screened abstracts of the retrieved citations for potential inclusion. For the search on specific
programs, one reviewer screened the abstracts and a second reviewer screened the abstracts that contained the
first reviewer’s notes concerning the abstracts’ eligibility.
Disagreements about the eligibility of articles were resolved
by discussion and consensus between two reviewers. When
necessary, the complete article was reviewed to determine
eligibility. Where consensus could not be reached, a third
team member independently reviewed the abstract or
complete article and determined final inclusion.
Data extraction & risk of bias assessment
Two reviewers independently extracted relevant data
from each included article and entered the data into a
standardized pilot tested data extraction form. Information categories included: study design, participant characteristics, setting, health care providers, early discharge
planning or usual care intervention elements, occasions
of measurement, and outcomes. Two reviewers independently assessed the risk of bias of each study using
Page 3 of 9
six defined domains: (1) sequence generation, (2) allocation concealment, (3) blinding of participants, personnel,
and outcome assessors, (4) completeness of outcome data,
(5) selective reporting, and (6) other sources of bias [21].
Study authors were contacted if additional data were
required. Disagreements on data extraction and risk of
bias assessments were resolved by consensus with the
assistance of a third team member when necessary.
Consensus data from included studies were entered into
Review Manager (RevMan, version 5.1) computer software, using the double-entry option [24].
Data analysis
Where we had sufficient data and where studies were
comparable in terms of outcomes, we performed metaanalyses using RevMan [24]. Continuous and dichotomous outcomes were analyzed using a random effects
model to calculate a weighted mean difference (WMD)
and risk ratio (RR) respectively, with 95% confidence intervals (CI). A P-value < 0.05 was considered statistically significant for an overall effect. A P-value < 0.10 was considered statistically significant for heterogeneity [25]. Degree of heterogeneity is reported by the I2 statistic which refers to the degree of variation across studies [21]. In situations where heterogeneity was statistically significant, sensitivity analyses were performed whereby studies were systematically removed from meta-analyses to determine robustness of findings [26]. Decisions for removing studies during sensitivity analyses were based on their potential source of variability - duration of outcome measurement. Studies that reported outcomes at one year were first to be removed, followed by studies that reported outcomes for successively shorter periods of time. In situations where meta-analysis was not possible, narrative analyses were performed; and the proportion of studies which identified an overall effect for early discharge planning compared to usual care was reported. A P-value < 0.05 was considered statistically significant for an overall effect. Results Description of studies Searches of all sources yielded 79,578 citations of which nine studies met the inclusion criteria (Figure 1) [23,27-34]. Characteristics of the nine studies are provided in Additional file 3: Table S1. A report of the review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines [35] is provided in Additional file 4. A total of 1736 participants were included in this review. The average study participant was 79 years of age and female (60%); was admitted to either a medical unit [23,31-34], an orthopedic unit [27,30], or an intensive Identification Fox et al. BMC Geriatrics 2013, 13:70 http://www.biomedcentral.com/1471-2318/13/70 Page 4 of 9 Citations identified Additional citations through database identified through searching other sources (n = 80,611) (n = 125) Citations excluded on basis of obviously irrelevant terms Screening [e.g. angiotensin converting Citations screened after duplicates removed enzyme (ACE) inhibitors]a (n = 79,578) (n = 78,701) Abstracts excluded, did not Abstracts screened meet eligibility criteria (n = 877) Eligibility (n = 458) Full-text articles excluded, Full-text articles screened did not meet eligibility (n = 419) criteria (n = 410) Included Studies included in meta-analysis (n = 9) Figure 1 PRISMA Flow Diagram [35]. care unit [29] for either the medical and/or surgical management of a cardiovascular illness (76%) or the surgical management of a hip fracture (18%); and presented with other co-morbidities including hypertension, diabetes mellitus, cancer and pulmonary diseases. The average participant was cognitively intact [23,28-32]. Most studies (67%) were conducted in the US [23,28,29,31-33]. Studies that provided information on living arrangements pre-index hospital admission reported most participants as living in the community [23,28,31-33] with family or significant others [27,28,31]. Early discharge planning was most often initiated by nurses [23,28-30] within 24 to 48 hours of index hospital admission (Additional file 5: Table S2) [23,27,29,30,33]. Early discharge planning involved: assessing the needs of older adults for discharge home with a focus on functional needs [23,28-32]; providing education to older adults and where available, to their families or caregivers [23,27,28,30-34]; reviewing and adjusting medications [23,31-34]; transferring information to successive in-hospital healthcare providers or coordinating care with community healthcare providers [23,28-34]; and following-up with one or more home visits and/or telephone calls after index hospital discharge [23,28,30-33]. Where described, usual care included unstructured routine or standard discharge planning provided by nurses or physicians [28,30-32] that was initiated postoperatively [27] or after transfer from intensive care units one to three days prior to index hospital discharge [29]. Risk of bias Risk of selection bias resulting from inadequate sequence generation was low in seven of the nine studies [23,28,29,31-34]. Two studies either provided insufficient information to draw conclusions in this domain [30] or were considered not to have been properly randomized [27]. Risk of selection bias resulting from inadequate allocation concealment was low in five of the nine studies [23,27,32-34]. In the other four studies, risk of bias was unclear because allocation information was not provided [28-31]. Risk of performance bias relating to double blinding was either unclear because seven studies did not provide sufficient information to draw conclusions in this domain [23,27,29-33] or high because of the absence of double blinding [34]. Only one study was double blinded [28]. Fox et al. BMC Geriatrics 2013, 13:70 http://www.biomedcentral.com/1471-2318/13/70 Risk of detection bias relating to blinding of outcome assessors was unclear because five studies did not provide this information [27,29-32]. Only four studies were determined to have low risk of detection bias related to blinding of outcome assessors [23,28,33,34]. Risk of attrition bias related to completeness of outcome data was low in six studies [23,27,28,31-33] and high [29,34] or unclear [30] in three studies. Risk of reporting bias due to selective reporting was low in almost all studies [23,27-30,32-34] except for one study which reported outcome data on quality of life for a subgroup of the study sample [31]. All nine studies did not appear to be at risk for other sources of bias that were not addressed in prior domains. Effectiveness of early discharge planning In total, four meta-analyses were performed for the following outcomes: index length of hospital stay, hospital readmissions, readmission length of hospital stay, and mortality (Figure 2). Sensitivity analyses were not performed because heterogeneity was not significant. Narrative analyses were performed for older adults’ satisfaction with discharge planning and quality of life because the two studies that reported satisfaction with discharge planning and the four studies that reported quality of life employed different outcome measurement scales or did not report baseline data. Neither metaanalyses nor narrative analyses could be performed for caregiver or community healthcare provider satisfaction with discharge planning or for caregiver quality of life because none of the studies reported on these outcomes. Index length of hospital stay Index length of hospital stay was reported in seven studies [23,27-30,32,33]. Meta-analysis of these seven studies identified no significant differences in older adults who received early discharge planning compared with those who received usual care (Figure 2a). Hospital readmissions Seven studies reported on hospital readmissions: within one month [27], two months [28], three [30-32], six [34], or twelve months of index hospital discharge [23]. Metaanalysis of these seven studies identified that older adults who received early discharge planning experienced significa ... Purchase answer to see full attachment

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