The central theme in this study concludes that there was no policy-driven discharge planning with proactive and multidisciplinary approach led by the executive level in current practice. The need to establish a systematic discharge planning with standardized protocol was thus highlighted. From this central theme, two core sub-themes emerged: (i) barriers to discharge planning, and (ii) suggestions on the important components for effective discharge planning.
Theme 1: Barriers to Discharge Planning
Participants pointed out that there were many piecemeal discharge programs in different hospitals. For example, some hospitals had disease-specific discharge programs targeting chronic obstructive pulmonary diseases, stroke, cancer, cardiovascular disease, and kidney failure. Other hospitals launched an Integrated Discharge Support Program (IDSP) for the elderly aged 65 or above. The Hospital Admission Risk Reduction Program for the Elderly (HARRPE) score was used to screen high-risk hospital readmission patients who would be recruited to the IDSP in selected hospitals. A nurse would visit the patients within 24 hours upon discharge followed up by visits from a physiotherapist, an occupational therapist, and medical social workers if necessary. Telephone nursing consultation service, liaison nurse for post-discharge service, and one-estate-one-nurse were other examples. Most participants identified a number of barriers to discharge planning, which were broadly described: system, clinician/healthcare professional, patient, and social factor [
21].
1.1 System Factor
Most participants expressed the system barrier as one of the major inhibitors to discharge planning. A few participants pointed out that premature discharge was due to the limited number of beds in the hospital. Owing to this pressure, some patients had very short hospital stays and were discharged too early:
"Since it is impossible to add extra beds, the length of stay must be short. Thus, there is a problem in having good discharge planning; (some patients) have to be discharged three days after admission." (6D, Nurse)
"The turnover rate and caseload in acute wards are very high... so, physicians have no time to discuss the discharge plan with the patients or their carers in detail." (6E, Community Nurse)
Participants also expressed there was some policy issues, including lack of guidelines or policies for the standard care pathway, inflexible IDSP program policy, poor medication system, and poor regulation of old age home quality:
"The care pathway is available, but it is led by the physician... If the physician does not initiate... (we will miss the patient)... Thus, if there is a policy/guideline, if the physician misses it, nurses will pick it up..." (3D, Doctor)
"We see the patient is still high risk for readmission... upon referral... they said the IDSP program cannot recruit the patient because the case is closed." (4C, Nurse)
"For changing the medication dosage, the system cannot facilitate... even though we talk to the pharmacist .... cannot change... For example, the patient is on twice daily before admission, now he is on once daily upon discharge, so the patient will have excess medication at home (but it is impossible to only print out the new medication dosage label)..." (6E, Community Nurse)
"The quality of old age home is varied...which may reflect the poor regulation..." (2B, Medical Social Worker)
Furthermore, some participants mentioned that discharge planning was a challenging task due to manpower shortage and heavy administrative work:
"Even if we have a clear clinical pathway and many pre/post discharge programs... we don't have enough manpower to follow or conduct... we already have many cases..."(6G, Occupational Therapist)
"They (physicians) have many administrative work... as a middle-level manager, we should support them, not only care for their clinical work but also support their involvement in discharge plan." (4E, Doctor)
In addition, majority of participants highlighted that communication and record transparency among healthcare disciplines were poor:
"We don't have a formal face-to-face communication... we all communicate through the chart recording."(6F, Physiotherapist)
"Communication is one-way... we only refer from acute to rehab, followed by MSW, placement problem, short course of in-patient rehab, and then home..." (3G, Doctor)
1.2 Healthcare Professional Factor
The healthcare professional factor is another identified barrier. Some participants pointed out that community nurses were not empowered to involve discharge planning:
"We (community nurses) are passive... we would like to be involved in ward round or case conference, we can give advice on whether the case is ready to be discharged or not." (6E, Community Nurse)
Participants also mentioned that physicians' documents were unclear and their assessment was incomplete:
"Sometimes, we want to contact the physician but he has rotated to another hospital... or he does not have enough information due to an incomplete assessment." (6A, Doctor)
Participants also highlighted the low awareness of physicians and nurses on patient's social needs:
"We don't worry (about) the clinical part because the physician cares for it... but for the patient's social need, the physician is not mature enough to do so..." (4E, Doctor)
1.3 Patient Factor
Participants further highlighted patient factor as barrier to effective discharge planning. They pointed out that the patient has a lack of knowledge of medication treatment:
"The biggest problem is medication... the patient does not know how to take... though we explain to him upon discharge... he doesn't understand..." (6E, Community Nurse)
Patient's preference was also highlighted by the participants. This is an important aspect to be considered, apart from the lack of medication knowledge, because some patients have a strong desire to stay in the hospital or refuse transferring to an old age home:
"The most challenging is the preference of the patient or his/her family... e.g., the patient's situation is worse after stroke... doesn't want to leave the hospital... and we don't have any regulation to discharge the patient." (6B, Medical Social Worker)
"Some patients don't want to live in an old age home... we know the patient must be readmitted if he stays at home... because he does not have any carer at home."(6E, Community Nurse)
1.4 Social Factor
Participants highlighted the service availability issues in terms of waiting time, patient's affordability, and inadequate equipment. Following are some typical comments related to these issues:
"The patients sometimes need to wait for 2-3 days for post-discharge support service... Also, there is no service available on weekends." (6B, Medical Social Worker)
Participants further pointed out that unmatched need, transportation issue, and time gap were the most serious problems:
"Transportation is the biggest barrier to access the post-discharge support service...due to no transportation available, the patient cannot go to day center or clinic follow-up... Even though the patient pays, he cannot get the transportation service." (6F, Physiotherapist)
"For the referral to day care center, the patient has the referral letter from MSW upon discharge and is then assessed by the Department of Social & Welfare after discharge; thus, there is a time gap between the patient discharge and the service available." (6B, Medical Social Worker)
In addition, participants expressed there was poor multidisciplinary communication and coordination between hospital and community service provision:
"We are in the multidisciplinary team... really want more communication among us..." (6C, Medical Social Worker)
"If we find out some difficulties, we sometimes cannot find patient's medical chart because it is already sent to the record office... We cannot find the responsible person for answering the question. We really want direct dialogue..." (6E, Community Nurse)
Theme 2: Suggestion on the important components for effective discharge planning
Various suggestions were provided by the participants regarding the barriers to discharge planning. Most of the participants agreed to have early screening to identify high-risk re-admitters using a simple screening tool. Having the screening tool installed in the information technology system would be beneficial because healthcare disciplines in different settings, e.g., acute hospital, rehabilitation hospital, and community-based service provision, would be alerted regarding the readmission risk of the patient. Implementing a standard screening procedure requires protocol and a policy-driven approach toward every staff member.
"I agree with others' suggestions that (once the patient is admitted to the hospital), we should perform the screening to identify high-risk readmitters, then each discipline will do his best to help... We also have a checklist to make sure everything has been done before the patient is discharged... Everything should be protocol-driven..." (3D, Doctor)
"We want a standardized (discharge planning) protocol, so everyone knows when to perform... even patients know clearly what the procedure is or if he would be involved" (6E, Community Nurse)
Participants further pointed out that the discharge planning should be a multidisciplinary approach, with clear roles for each healthcare discipline. A few roles were suggested, such as designated nurse or physician for discharge planning, clinical pharmacist for medication reconsideration, and trained volunteer for facilitation on psychosocial need:
"Once the patient is admitted to the hospital, we should let the patient know whom he can ask for help. Otherwise, the patient is confused with different party roles."(6E, Community Nurse)
"Now, a clinical pharmacist has been performing medication reconsideration for two years... we feel they can help a lot... we and patients know clearly the medication... Also, there is medication education for patients as well." (6D, Nurse)
"We have trained many volunteers and they are capable to help more especially on the patient's psychosocial need... we should make use of them, e.g., they can provide a brief orientation for each hospital admitter." (6E, Community Nurse)
Apart from the screening and manpower management, participants emphasized the provision of psychological support for patients, as well as education for managing the need of patient and carer:
"Patients' psychological problem is one of the major issues. We should pay more effort on the social support, then everything will be more smooth..." (6D, Nurse)
"Ninety-year-old lady falls and hopes to recover within 2 weeks... (5A, Medical Social Worker) Thus, we should communicate with the patient and her family early... we should give them the right information as early as possible... Otherwise, there will be an expectation gap between healthcare staff and patient." (5F, Physiotherapist)
With regard to community service management, participants highlighted the coordination between HA and community service provision. Allocation of more resources in the community service provision needs to be reviewed or improved:
"If more resources are allocated in the community setting which can enhance the pre-discharge support and decrease the readmission, it will decrease the cost on acute care and workload of healthcare staff in the acute setting. Thus, don't think the expensive community service is not worth it... it can decrease the cost in A&E and in-patient hospitalization." (6G, Occupational Therapist)
Some participants suggested changing physician's culture and/or enriching physician's training by emphasizing the psychosocial component:
"We don't worry about the clinical part, but we really worry about the social matters. The physicians are not mature enough to be aware of patient's social need... They should let a nurse to step in to help or a senior physician should play a role for guidance." (4E, Doctor)
A few participants expressed that, in some cases, family or carers were not available to take care of the patient at daytime, and the family cannot support the 24-hour domestic helper in terms of salary or living space. Thus, the participants suggested designating a daytime carer to provide round-the-clock care and supervision:
"Just like daytime domestic helper, she can stay with the patient... Most of elderly are very frail and need round-the-clock care... The government can allocate a pool of money to pay for the daytime domestic helper who can be the family member, then the family member can quit his/her job and take care of the elderly without affecting living cost..." (4B, Occupational Therapist)
Finally, majority of the participants suggested the discharge program should target all high-risk re-admitters without age limit. The follow up period of post discharge program should be flexible according to patient need. The group mentioned that the current IDSP should be more flexible and not limit follow up to only six months for selected high-risk cases. The participants agreed on the benefit of the IDSP on patient's health and readmission rate. Thus, they suggested IDSP could cover high-risk patients aged ≤ 65 years.
"Now, IDSP only serves geriatric patient... but some adult cases which do not reach age 60 are at high risk for readmission. They only receive CNS or GOPC support, it is not enough. IDSP is very good because it is a multidisciplinary approach and provides a platform for continual care and multidisciplinary communication. Since there is a time gap issue for community service, IDSP could bridge the gap." (2E, Occupational Therapist)
The summary of overall findings is shown in Table
2.
Table 2
Summary of important component of results
No standardized policy/protocol for discharge process |
No standardized tool for facilitating the discharge process |
Piece-meal approach in individual hospital |
Discharge program targeting high risk readmission which is based on clinical judgment and varies across hospitals |
Disease-specific discharge program for selected diseases |
Barriers to Discharge Planning
|
System Factor
|
Lack of guideline or polices for the standardized discharge process/care pathway |
Piece-meal program as pilot and issue of inflexibility of program |
Pressure on bed availability |
Poor medication system in hospital |
Poor communication among healthcare disciplines |
Issue of manpower shortage and management |
Poor regulation of care quality in old age home |
Professional Factor
|
Unclear role of each disciplines |
Nurses not empowered to initiate discharge planning |
Unclear or incomplete chart documentation |
Low awareness on patient's social needs |
Patient Factor
|
Lack of knowledge of medication/treatment |
Mis-concept of hospital discharge |
Social Factor
|
Issue of services availability - waiting time, affordability, equipment loan |
Issue of un-match needs of patients - transportation, time gap of service availability and hospital discharge |
Poor communication/coordination between hospital and community service provision |
Suggestion on Importance Components for Effective Discharge Planning
|
Standard screening tools to identify high risk readmission case with protocol approach and policy-driven |
Discharge planning with multidisciplinary approach |
Clear role of each multidisciplinary identified in the discharge planning |
Designed nurse/physician for discharge planning as contact point |
Clinical pharmacist for medication reconsideration |
Trained volunteer for identification/facilitation on patient's psychosocial needs |
Effective manpower management |
Patient education: medication/treatment, concept of discharge process |
Coordination between Hospital Authority/hospitals and community service provision |
Enhance training/education on patients' psychosocial needs for physicians |
Home carer support program to facilitate transition period from hospital discharge to home |