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Evidence-Based Healthcare & Public Health (2004) 8, 332–334

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REVIEW

Co-ordinating discharge of elderly people fromhospital to the community

S.G. Parker, MD FRCP�, S.D. Lee, MB BS MRCP, R. Fadayevatan, MD MPH

University of Sheffield, Sheffield Institute for Studies on Ageing, Barnsley District General Hospital

Key pointscan be hazardous. Without sufficient support in the

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Inpatient hospital care for frail older people maybe associated with loss of physical function andindependence, leading to a high risk of hospitalreadmission.

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Coordinated discharge of elderly people acrossthe hospital-community interface reduces hospi-tal readmissions by about 17%. It is at least assafe as non-coordinated discharge arrangements.

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Specific interventions for achieving effectivejoint discharge include multidisciplinary teamsusing comprehensive geriatric assessment acrossthe hospital-community interface; comprehen-sive discharge planning; discharge co-ordinators(usually a specialist or advanced practice nurse),and patient empowerment with patient educa-tion.

Background

Older people are frequently admitted to acutehospital care. For example, in the US, the over-65 saccount for 36% of hospital admissions and almost50% of hospital expenditure.1 For frail, elderly

ee front matter & 2004 Elsevier Ltd. All rights reservhbc.2004.09.034

ng author.ess: s.g.parker@sheffield.ac.uk (S.G. Parker).

people, the post-acute period in the community

community, people’s physical weakness followingillness, hospitalisation and disruption to formal andinformal care arrangements can result in decline inphysical function, independent living, and in-creased risk of re-admission to hospital.2,3 Coordi-nated discharge procedures, which ensure follow-up care in the community, might, therefore, be animportant means of ensuring the safe and effectivetransfer of older people between inpatient hospitalcare and community based, home care.

Review of the evidence

This review, which updates previous work,4 pro-vides the latest evidence on whether a coordinatedapproach to discharging elderly patients fromhospital reduces readmission to hospital, withoutcompromising safety.

Methods

Study design: Systematic review.Search strategy: We searched Medline (1996 to

August 2004), EMBASE (1996 to August 2004),CINAHL (1982 to December 2003), the Cochrane

ed.

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Co-ordinating discharge of elderly people 333

Library database of systematic reviews (2003/04),the NHS Centre for Reviews and Dissemination andClinical Evidence (Issue 10).

Inclusion/exclusion criteria: We included rando-mised controlled trials that examined interventionsintended to modify discharge, which included bothhospital and community-based elements, in peopleage 65 years or more leaving inpatient hospitalsettings (teaching or district general hospitals andcommunity hospitals), and which reported onhospital readmission. We excluded discharge fromnon-high technology care settings, such as nursinghomes, or ambulatory settings such as day hospitalsand outpatient departments.

Data extraction and synthesis: Data were ap-praised by two independent reviewers. We synthe-sised readmission and mortality data using meta-analysis.

Results

The previous review found 15 randomised con-trolled trials that met our inclusion criteria. Over-all, these interventions versus usual-care reducedsubsequent hospital readmission rates by about 17%(readmission rate ratio 0.829, 95% CI 0.690 to0.995, n=3567). The updated searches identified 3additional randomised controlled trials, whichshowed a similar effect size (readmission rate ratio0.77, 95% CI 0.60 to 0.99, n=671). Those studies,which reported mortality, showed no adverse effectat 6 or 12 months (6 months OR 0.61, 95% CI 0.37 to0.99 n=2040; 12 months OR 0.95, 95% CI 0.65 to 1.4,n=2747).

These trials examined four main types of co-ordinated discharge:

1.

Six trials of comprehensive geriatric assessmentby multidisciplinary teams across the hospital-community interface, using formalised assess-ment tools, which inform or prompt furthertreatment or management.5–10

2.

Six trials of comprehensive discharge planning,which is usually carried out by a specialist oradvanced practice nurse working to a definedprotocol or care pathway and organising servicesacross the transition from hospital to homecare.11–16 Comprehensive discharge planningincludes a pre-discharge assessment of thepatient and carer; development of a patient-specific discharge plan, and maintenance ofcommunication with the patient’s hospitalteam. It is designed to improve care by improv-ing the appropriate utilisation of hospital beds,

reducing bed blocking and reducing health carecharges for older people.17–19

3.

Three trials of discharge support, designed tosupport elderly people at home, followinginpatient care.20–22

4.

Three trials (one with four reports) of patienteducation designed to improve people’s abilityto manage aspects of their care, such as use ofmedications, following discharge from hospital.23–28

Conclusions (also see Editorial, pagedoi:10.1016/j.ehbc.2004.09.036)

Discharge arrangements across the hospital-com-munity interface are safe and are associated withreduced readmission to hospital. Effective crossboundary working between health and social,hospital and community care systems is important,particularly where there is a risk of adverseoutcomes from prolonged hospitalisation and pre-ventable readmission. The cost consequences arenot yet clear.

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