Journal of Clinical Niirsiiiti l ' )9 .? ;2: 179 185

Experiences of elderly patients concerning discharge from hospital

ALISON J. 'ril'.RNKY BSc(SocSc-Nurs), PhD, RGN

Director, Nursing Research Unit, University oj Edinhurgh

S. jOSK C : L ( ) S S BSc(llons), MPhil, PhD, RGN

Research Felloii', Nursing Research Unit. L'niversity of Edinburgh

UARRIKT C. H U N T E R MA, SRN, (̂ N, HV Dip. & Cert.Formerly Research .tssociale. Nursing Research I nit, Unirersilj' oj'lulinbnrgh

M.AUREEN S. MACMILLAN HA, PhD, RGNResearch Fellow, Nursing Research Ihiil, University of F.dinbnrgh

.icccpted for publication 22 Jannary lO'Ki

Siinimary

• Problems surrounding the discharge of patients from hospital have been well-

doeumentcd in the research literature and highlighted in reeent Audit Commis-

sion reports.

• The need for effective discharge planning and post-discharge support is

increasing as lengths of stay in hospital continue to tall.

• Llderly patients are in particular need ol well-planned discharge.

• This paper reports the findings of an exploratory study in which elderly

patients were interviewed before and after discharge from hospital.

• Three main problem areas which were identified are diseussed:

lack of preparation for discharge;

difficulties in managing at home after discharge;

limited provision of health and social services in the post-discharge period.

• It is suggested that nurses are in a key position to improve discharge planning

and procedures for patients (particularly the elderly) returning home from hospital.

Keywords: community care, discharge planning, elderly.

search Unit at the University of I'Alinburgh. It is a topic

' " ' which has increasing importance as the elderly population

The subject of discharge of elderly people from acute rises and increasing numbers of elderly patients are being

hospital wards is heing investigated by the Nursing Re- discharged from hospital. With greater emphasis on earlydischarge, the need to improve discharge planning and the

Correspondence: Dr A.J. Tierney, Nursing Research Unit, Depart- provision of-appropriate follow-up care for elderly patientsment of Nursine. Studies, Ihiivcrsity ol lulinbnri^h, 12 lhicclencli Place, r. l •. r .• - • i i c l i,.,. •' , , . , „ , , , , , , . , , , • after hospitalization is reeognized and, for example, haskdinbioxh hi 18 91,11, (A ' r ^ i

been highlighted m reeent Audit Commission reports'fins research was funded by t h e Chief S c i e n t i s t 0 1 u c ol t h e S O H l l D . , , , , , ^ i i " n i n \ - I M I I ,- > • • a - • vThe views expressed in Ihis papa do not necessarily rejiecl those of the (I'^'^l^ '9'^^)- 1'l^' Pmblems of aehievmg effeetive dlS-^funding body. charge planning are also a matter for concern in the light of

179

ISO A. |. Ticfnc\ ct ul.

the MIS and Cotntiiunity Care Act (l)oll, 1989a). Thisstipulated that local aittliorities will take over the cat-celement ol social security budgets by 1993. Social serviceswill be required to appoint care tnanagers to ]ittrchase theajipropriate resources for individuals, so close liaisonbetween hospital and local authority stall will becotneessential. (Concerns have already becti voiced about the]i()ssibility ihat discharges could be delayed when socialservices assume t-csponsibility lor assessing anti securtngthe provision of support servtccs lii ihc community (Anon.,1993).

The importatice of proper discharge arratigements forllie elderly and follow-up support in the community isincrcasitigly recognized by jiolicy-tnakers, health-servicematiagcrs and practitioners alike. Interest in systetnaticdischarge planning, already a wcll-dcvcloped concept inthe L.SA, appears to be growitig rapidly iti Uiis coutiiry.Discharge planning, il has been suggested, 'can potentiallyreduce patient length ol hospital stay, prevent rchospilali-zation, enhance pattent oulcotnes luid lessen the burden ofcure on the families' (Naylor, 19'K)). .Such claims have far-reaching itnplieations bul, as yet, there is no real evideticeol their validity.

The lirst part ol this paper offers clear justiftcation forgiving close attetition to the intricacies of discharge plan-tiing for elderly people. Tbe second part reports on anexploratory study which clearly showed that probletiis at-cstill encountered by elderly people t-eturning home frotnhospital.

Biickgroimd

.\ recent Audit (^otntiiission t-epori (1991) indicated thatitnprovements do tiol seem lo have tbllowcd the Depart-ment ol I Iealth (I9cS9b) cn-cular and gutdchncs on Dis-charge of Patients from Ilospilal. There at-c two majorfactors which tnake discharge planning for elderly people asubject which requires urgent attention. l''irst, currentdetnographic changes mean that the proportion of elderlypeople in the popuhilion is steadily on the increase..Second, discharge phmnitig has been shown consistetitly tobe inadequate in a variety ol settings throughout the pasttwo decades.

IN(:t(l..'V.St\(i Nt.VtIihR.S i.t.t)i;Rt.Y PAI 1

Problctiis resulting from rapid dischat-ge are likely tobecotne tnore acute because the utilization of hospitalservices by older people has increased dratnalically atidcontinues to rise according to the statistics as sunitnarizcd,for example, by Victor (1991). She noted tbat over the

pet-iod between 1971 and 19(S5, hos|-)ital discharge ratesrose overall by 25",,; anti for patients agctl 65 74, the rtscwas a little over ^S^]^t, with the iiict-easc rising to 46'/i, tnthe 75+ age-group. Although elderly people still tend toslay iti hospital for longer than comjiarable youngerpatients, iheir average length ol stay has redticccl dramati-cally over the satne 15-year period. l''or patients aged 7.">years atid over, the decrease has been in the ot-der of 40 o(from 41 to 25 days).

These dramatically iticreascd dischat-gc rates, coupledwith the reduction in length of slay, could create anincreased workload for nurses and other service providersin ihe community. It seems unlikely that any substantialincreases in slatfing will be offered lo help cope with therapid turnover ol elderly patients al a lime when services inall areas of the NIKS are being 't-alionalized' and demandson ct)nitnunily serviees are increasing. Initialivcs It) cotn-pat-e the elfeclivcncss of tnanagemctit of ihe discharge ofelderly patients from hospital should, tlierclot-e, be apriority if diificulties in the community are lo be nitnt-mizcd and miprovements at-c to be achieved vvilhiii exist-ing levels of stalling and service iirovision.

t'l.ANNINC; A.MI) IT.S l'KOtit.t:M.S

The areas in need of attention are well tlocumcnted Irotnresearch which has idetililied the ]:)t-oblems oi recentlydischarged palients and has produced clear recommenda-tions throughout the last 20 yeat-s. Studies have consis-tently highlighlcd the Ibllowitig shortcomings.• Poor cotntiumicalion bclwcen hospital anti conmutniiy

(Skcet, 1970; At-mitage, 1990; Cut-t-an cl ai, 1992; Meat-a(•/ ai, 1992; Williams ,•/ ai, 1992).

• Lack of assessment and planning for tlischarge (Skeet,1970; Ilat-ding & Modcll, 1989).

• Inadequate notice of discharge (Victor & Vetler, 19<S(S;Harding and Modell, 1989).

• Inadequate discussioti with palicnis and their carers(Vic-tor &Vcttct-, 198H;(;()ngdon, 1990; Klop r/^//., 1991).

• Over-reliance on informal support and lack ol (or slow)statutory service provision (Waters, 1987; Victor &Veller, 1988; jaekson, 1990; Williams & l'illon, 1991).

• Inattention to the special needs of the tiiosl vulnerable(Harding ik .\4odcll, 1989; Mamon ,•/ ai, 1992) atulwasted or dtiplicalcd visits by community nurses (Artni-tage, 1990).The Audit (Commission (1991) acknowledged contitiued

jn-oblems surrounditig discharge anti t-econnnended thaiihcy should be addressed by -action concerning -adminis-trative arrangements lor discharges, tlischarge planningiintl co-t)rdinatit)ii, access to rest)urccs outside the hospital.

Discharge iilanning tor eklerl) patients 181

better relations with hospital social workers and the collec-tion of appropriate management information.

An exploratory sttidy

The Nursing- Research Unit has been working in collab-oration with a large leaching hospital with llie objective ofimproving discharge j-ilanning. The hrst stage of work tookthe form of an exploratory descriptive study to provide apreliminary ]-)icture of the problems and processes sur-rounding the discharge of elderly patients in that hospital.

The part of that preliminary investigation which isreported here focuses on patients' views and experiences ofdischarge from hospital. The experiences ol a conveniencesample of 40 ]-)atienis aged 75 \cars or over were examinedon the basis of case notes and from structured interviewswith them. Patients from eight wards, covering medical,surgical, oj-ihthalmic and geriatric assessment specialtieswere included. l'".ach patient was interviewed within 36hours prior to discharge and (if willing) at home 7-10 daysafter discharge.

'I'his group of 40 ]iatients was only a very small sampleof the total of 1465 patients aged 75 and over who weredischarged from this hospital during the 3-nionth studyperiod. Obviously, therefore, the views they expressedcannot be considered truly representative ofthe majority.I'urther, while this paper Ibctises on patients' reports oftheir dilliculties and the more negative aspects of dis-charge, many examples of good practice were alsoobserved, btit they are not detailed in this report.

ciiAtJAcn-.Rt.srics ot' xtit-: I'Atn-.Nrs

Complete data sets were obtained from 34 of the patientsselected. The jiatients' ages ranged from 75 to 94 years(mean <S2-3); 25 were under 85 years of age and nine wet-eover 85. Twenty-one ofthe patients were women and 13were men. Just over half (21) of the patients werewidowed; nine were married and three were single (thestatus of one was not recorded). The patients had been inthe hospital for dilTcrcnt periods ranging frotn 3 to 57 days(mean 14-0). The main medical problems for whichpatients were undergoing treatment were varied and,predictably, multiple pathology was common.

Thirty-three ofthe patients returned to their own homeon discharge, the other to her daughter's home. Twentywere living alone at home, nine with their spouse, threewith their son or daughter and two with someone else. Ofthe 20 who lived alone, 19 had access to a telephone and allbut one had a relative, friend or neighbour who could becalled on for hel]-) if needed.

The type of iiceonimodation varied Irom easy-to-man-

•.\<ic, well-healed ground-floor homes to cold, poorh fur-nished flats and, unsurprisingly, anxieties about managingstairs were common. One elderly lady livetl in a typicallulinburgh flat and, clearly, she had counted the 72 stepsup to her llat on many occasions!

Three problems surrounding discharge from hospitalwhich patients talked about in these interviews have beenselected for discussion in this paper. These are: (i) lack ofpreparation for discharge and inadequate notice; (ii) difli-culties in managing at home alter discharge; and (iii)limited provision of health and social services in the post-discharge period. These particular problems ha\e beenchosen for discussion because they appear to be continuingproblems which must he addressed if improvements are tobe achieved in discharge procedures and post-dischargesupport.

l..\CK ot ' t'RKPAR.\TtON t-'OR niSCtl.\R(iK

Patients were asked in the ward interview whether anyonein the hospital had asked how they expected to manageonce back at home. Only 14 of the 34 patictits recalledhaving been asked how they would manage alter discharge;19 said they were not asked and one could not remember.Accommodation had been checked by an occupationaltherapist for only seven patients e\en although it wasknown that 20 ofthe 34 patients would be living alone afterdischarge from hospital.

Patients were also asked abotit notification ot discharge.This varied considerably among the patients. Almost athird (11) had been given less than 48 hours' notice oldischarge. The majority of patients (23 34) were told by amember ofthe medical stall'about the proposed dischargedate and a number (9) had been informed by a member olthe nursing slafl' (two patients cotikl not retncmbcr whotold them).

Unpronipted, some patients voiced their concern aboutthe short notice given. One, for example, said she felt thatthe communication of her discharge was 'abrupt' and shewas 'dismayed to be tokl out ofthe blue' that she would gohome because she was unable to contact anyone to collecther at such short notice.

Patients were asked if they felt ready to leave hospital,whether the discharge decision had been discussed withthem, and for their views on their length of stay. Twenty-live patients said, when they were first tokl, that they hadfelt ready to be discharged but six did not feel ready andthree felt unsure. Six patients had had the decision aboutthe timing of discharge discussed with them; 28 had not.Thirt>-one felt that their stay in hospital had been theright Ictigtii; two felt it was too short and one was un.stirc.

1,S2 .A. |. Tiertie\ cl ai

.\ few patietits were clearly atixious about feeling unreadytt) go hotnc. One saiti she was being discharged 'tooquickly, too unwell and needing a bil lt)nger in hospitalwhere il was warm and food was providctl'. Another saidshe was very ap|-)rehensi\c about going home because shewould not tnanage as her eyesight was poor, she ct)ukl nt)iwalk properly anti could not even remember what her Hatwas like.

.'\s pt-eviously stated in the introduction, these findingsof short notice of discharge, lack of consultation andanxieties about readiness for discharge have all featured inpreviously reported surveys ol recently discharged ekierlypattcnts.

D I I t t C l . l . t l t : . S I N M.-VNACilNCi

In the prc-discharge inierviews patients were asked howthey had managed with a range of home tasks andhousehold routines before coming intt) hospital and howthey expected to manage after their discharge home. Later,at the home interview, patients were askctl how they wereactually tnanaging these same t-outine tasks. The findingsare shown in Table 1.

It can be secti that the gradietit is consistently in thedirection of patients managing le.ss well considerably lesswell than bcftjre admission to hospital and even less wellthan their expectations of tnanaging expt-es.sed only a shorttime before discharge. The tasks which stand out asapparenti} causing mt)sl dilliculty arc going shopping,washing and ironing, and pt-eparing meals. Why thepatients .st)nielimes overcstitiiated their expectations of

Task

Making tea cotieePreparing mealsPutting heating onRoutine housewotkWashing and ironing(iellmg shopping(.oileeting tiewsjiapers(Jetting librar\ books( l e t t i n g p e n s i o n ; i i i ( j n e \

I'aving rent bills

(.ollecting prescnpl lon.s

( l e t t ing hearing aid l ia t tenes

1 .ooking atler pet(s)

Asked at ward

interview

\hinagedpreviously1

2530

14IS1967

172.!1.1

f)

4

l- \̂pcctcdto manage2

3t)

2.12.S12

1312

41

16

25126

4

Asked at homeinterview

Actuallymanaging3

25

1725<)S

731

11

18115

5

*

( 6)( - H )

( - 5 )

( - 5 )

{- 10)

( - 1 2 )

( - 3 )( 1)

( 6)

( -- 5)

{ 2)

( 0( 1 1)

managing at liotne is a mailer for speculalit)n, but the lactihat they tlid is oi relevance to discharge planning.

Preparatit)n for managing wilh metlicalions at ht)mc isknown to t-equirc iniiirtjvetneni and patients in this studyc-t)nrtrmed the tieed for this. The patietits were dischargedon widely varying nutnbers of medications (15 on one t)rtwo drugs, 1.1 on .15 and 6 on 6 10) bul t)nly nine tjl'lhcmrcpt)rled having been given insiruclions before leavinghospital t)n how to lake their tnedicatitins. Otic patient,dischat-ged home after surgery Ibr glattct)ma, was highlyanxious about her t-egimc of live dilfet-ent kinds of eyedrops and ct-ilical of ihe fact that she had not been warnedto expect some itnpairment t)f vision after iheir instillation.

Again, patients het-e wci-e t-eiterating the necessity lot-asscssnient and preparalit)n prior tt) discharge which matiyresearch reports have jiointed out t)ver the yeat-s.

l.I.VlItKt) HKAt.TIt AND SOCIAt. St':KVI(:t..S .SUt'PORT

In hospital, patients were asketl about pre-adtnissioncontact with their GP and ct)nimunity nut-sing staff,pt-ovision of hotnc help and nical.s-on-wheels services, andabout supjiort from health and social services which theyexpected to receive alter di.schargc. Pi-cvious regular con-tact with ihcir CiP was rept)rted by 21 patietits; live hatibeen in contact with a health visilor and three patients hadbeen t-eceiving district nursing .services.

(!P vtsils

A visit (Vt)m ihe CiP soon af'ler getting htimc was definitelyexpected by 16 ofthe .14 patients. In the event, 20 patients

Table 1 Numhers ot palienls

tnanaging routine lasks altet- di.schat-ge

' t )ilVcrclux- lictwccn ».t)Uinins \ and .'>.

Discharge plamiitig lt)r ekierly patictits I8.1

had been visited by their CiP by the tenth day afterdiseharge. 1 lt)w-ever, t)nly two of these visits hatl bccti tinthe first tlay home with live on the sect)titl and three oti thethird day. Nine ofthe 20 GP visits wei-e t)n ihe eighth tirninth day pt)st-discharge. Three patietits volunteered theitifortnation that, tin\isited as yet, they had felt neglectedby theii- CiP. It is not possible to say whether ihe i-ate andspeed of CJP visits to this small group t)f patictits washigher t)r lt)wx'r than avet-agc. 1 lt)wcvcr, t)l relevaticc ts thefact that, for reast)ns ol research prt)tt)ct)I, all of thepatients' CiPs were setil a ]-)crst)nal letter by pt)st t)n t)rbefore ihe day t)! tliseharge with nt)iificatit)n ol tbe tlis-charge dale and the planned hotne interview.

were asked who they consitleretl tt) be their main helper.I*'t)r 18 patients this was a relative, ft)r tiitic it was a spouse,ft)r four a tieighbtiur anti ft)r t)tie il was a frtend. Twopatients could nt)l name a helper.

The majority of patictits (26/34) had a t-elative or clt)sefriend living in the same town, this being in the sameneighbourhood in 12 cases. Since being htitne from ht)s-pital, .ll of the 34 patictits had been visited by t-clativcsand/or friends and neighbours. Twt) patients had beenvisited by their minister and one by a vt)luniary worker.Asked if they had fell ltinely at all since cotning hotne fromhospital, 25 patients said they had not, but four admittedto having been lonely.

DislricI ntirsinu; services

A visit frt)m the district tiut-se had been received by li\e t)f"the 34 patients in the lirst 7 10 days after dischat-gc. Twt)other patients expressed the view that assistance from adistrict nurse wtittid have been helpful, in both cases lorhelp to have a bath.

Health visitor

Nt)ne of the palients t-cccivcd a \isit by a heallh visittir inthe period between dischat-ge and the home interview.

Home-help services

llt)me-help services were being prt)vided for 18 palients,t)nly t)ne tnore llian the nutnber wht) had been t-eceivinght)me-help assistance prit)r to admission to ht)spital.

Meals on wheels

Meals t)n wheels were being provided Ibr tht-ee patients,one less than the number pt-cvit)usly in t-eceipt t)l thisservice; the reason lt)r this t-eductit)n is nt)t ktiown.

Other services

Other services lt)i- discharged patients wet-c infrequentlyreported. 1 lome visits frt)m a st)cial wtirker had beenreceived by iwt) palients and trom an occupational thera-pist by three patients. Low levels of statutory servicepi-t)visit)n in the pt)sl-tlischarge perit)tl have been reportedin many previous studies.

Informal support

The informal support which patients in this study wctereceiving was clc-.irly viewed as indispensable. Patients

Varying circumstances atid individuality

Altht)ttgh the patients iti this stutly hati much it-i ct)tnint)tithe interviews brtiught ltitt) focus their varying circum-staticcs. Wlicti t-csearch surveys rcpt)rt findings iti tertns t)fct)llectivc data and statistics, the variations atid the indi-viduality ofthe people very t)ftcn beet)me obscured. In anattempt to provide a flavour t)f the kinds of people theseititerviewees were, atiti how they lived, the research intet--viewer wrt)te st)me short descriptive accounts, and threeare included here by way t)f illustratit)n. The names t)l thepatictits have been changed tt) ct)nccal itlcntificatioti.

M\< roM t!t<tt)t;t-.

This patietit, wht) was 82 ycat-s t)f age, exemplilictl the bestsupptirted gt-t)ttp ot the patietits ititcrvicwctl tncn bemglt)okcd after by their wives. 1 Ic had becti adtniitctl tt)hospital lollowing a rt)ad-traffic accidetit atid he also hadtliabetes. Iti the warti he was cheerfully ctitihtletit abttuttnanaging al ht)mc, but admitted that he was totallydependent t)n his wife, aged 84. Their stin lived wilh them,but he was rat-ely at ht)ine tt) help. Bt)lh ihc wife and thest)n had appealed tt) the hospital to delay discharge as MrsBridge felt that she could nt)t cope alt)ne because, at thatpt)int, Mr Bridge could nt)t walk and t-equircd lifting.

Al hotnc he was seen in a tnucli more subdued frame t)fmind, but he was clearly well lt)oked after by a loving andcapable wile. However, she admitted to strain and tired-ness, and the need ft)r a hotne help, lor which they wet-etit)t seen as eligible. .\ district tiurse came in every day togive Mr Bridge his insulin atid the GP had visitedspt)titatict)usly t)ti discharge, saying that he would return in2 weeks. Perhaps the tnost redcctning feature t)f thissituation was the fact that .Mr and Mrs Bridge obviouslygt)l tin well together atid were well liked and integrated intt)their lt)cal ct)mmunuv.

184 A. |. Tierney et al.

MK.S \ 1 A K Y ( i R i : i : \

This 94-year-()ld woman who lived alone was in anahotrclhcr dillcrent siuuition and was perhaps ihc mostdisircssinjj patient amon;; those interviewed. She had beenadmitted lo hospital becatise o( dizziness and tmiltiple fallsat hotne. In the ward she cxj^ressed considerable anxietyabout her ability to cope at home. Although rather dealand virtually blind, she was a spirited and articulateperson. She said that tluring her stay in hospital her sighthad deteriorated further and she could no longer remem-ber the layout of her flat. Watching her in the ward, (heinterviewer saw the teeth-gritiing efforts Mrs Green madeto walk with the aid of a Zimmer frame to the bathroomand then get into bed. I ler legs and feet were very arthriticand severely oedetnatous. (Concern was expressed liy theward staff as tf) the feasibility of sending her home and theward sister admitted that the CiP had otily 'agreed' to haveher home if he had a guarantee that in the event of a crisisshe could he given emergency Part 4 accommodation.

When seen at home it was obvious that Mrs Cireen haddeteriorated markedly. She said that she was cold andhungry. There was no heating on at all in the Oat in spite ofthe free/ing temperature. The only means of heat was theeoal fire whieh she eotild not tnanage or a one-bar eleetriefire whieh was too unsafe to leave on. She stayed in bed,the bedding of which was inadequate and she was indanger of tailing every time she got up to the toilet. Themain support in this situation was the next-door neighbourwho herselfvvas over 80 years of age. She went in and outbut admitted that the situation was beyond her and shecould not lift Mrs (ireen il she fell. During the interview athome Mrs Green was quite distressed, saying over andover again, 'I've got to get out of here'. The flat was oldatid in a poor state of repair in a run-down tenement. TheGP had visited anti was concerned about her.

M R j l \ 1 l A I K I J A t H N

This patient, aged 80, was another seen at home in apathetic state, in contrast to his state in the ward. lie hadbeen admitted to hospital with left vetitricular failure,pulmonary oedenia and a chest infection. In the ward hewas regarded as a still-handsome and articulate man, and itwas easy to believe him when he said that he bad been atnilitant in the Trade Union niovement. Visited for theinterview at hotnc, he was found in an unheated room,lying in bed smoking and crying, with a eough indicative ofa chest infection. I le wanted to talk about his wile to wbornhe had been married for 34 years. .She had dementia andwas in a hotne and no longer knew him, and so Mr

l'airhairn felt that there was no point in visiting her.However, his two daughters were supportive and visitedhitn regularly. 1 lis GP had visited him and he had a honie-help, of whom he was very fond. A few days after this vtstthe was readmitted to hospital for a bronchoscopy.

Not all of the patients living alone at home were found tobe in a sorry state when visited in the post-disehargeperiod, but they were all vulnerable and arguably tnanycould have benefited from more practical help and emo-tional support. The nutnber ol patients in this exploratorystudy was small, and the sample not necessarily represen-tative, but the general picture which emerged was reflec-tive of the findings of larger sy.stetnatic surveys which, overthe years, have drawn -atlention to the problems of elderly,recently discharged hospital patients.

Although seope for improvement was evident, overallimpressions of the rnanagenient of the discharge of elderly|")atient.s in the researeh setting were by no mean.s entirelynegative given the large nutnber of patients involved andthe pressure on stalf and beds in this large and husyhospital. Concurrent ititerviews with nttrsitig, medical andother professiotial staff showed an ohviotis degree ofconcern for this group of potentially vulnerable patietitsand a great desire to be as protective as possible of thetn intheir discharge from hospital.

(Nearly, however, there were many aspects of dischargepractice which could be improvetl and this fact was wellrecognized by stall' in the hospital as the separate inter-views with them showed only too clearly (M.S. Mactnillati,unpubl. data*), (x'rtainly, from the interviews withpatients, (here was little evidenee of discharge arrange-ments or contiiuiitig care being systematically planned onthe hasis ol individually assessed circumstatices and needs.1 he exploratory study eonlirmed, therefore, that thereremains a need in (his hospital as in others for improve-ments to be made in (he ]")latining of discharge for elderlypatients returning hotne alter acute hospital care. Themain problems in need of attention appear to be welldefined and, as disetissed earlier, ex]ilici( recommendationsabout discharge planning have been set out and widelydissetninatcd to professionals (Doll, 1989h). Morerecently, these have been reiterated in The Pulioil's(Charier (Doll, 1992). This states what patients have aright lo expect coticcrning discharge Irotn hospital.

* lldipilii! sliiJJ's l>crccl>li(im iij risk (ISSIIIKIICII irilli llic diichart^c iijt'ldci'ly l)(ihc)iis jyoin Iltispihil, Ni/t'sin^^ Rcsciinh Vint, Umn'ysily i)jl.tlinhiireh.

Discharge planning for elderly patients 185

'Ik-lore you are discharged from hospital a decisionshould he made about any continuing health or.social care needs you may have. Your hospital vxillagree arrangements for meeting these needs withagencies such as commtinity nursing services andlocal authorities social service departments beforeyou are discharged. Yoti and, with your agreement,your carers, will be consulted and informed at allstages.'

There seems to be a clear consensus about what isrequired. So far, however, information describing il, howand where action has been taken to improve dischargeplanning, and the elVectiveness of such initiatives isunavailable. The time is ripe for nurses to take this issueforward, both by improving their methods of dischargeplanning and by evaluating ihe effectiveness of suchchanges in their j-jractice.

References

Anon. (1993) Discharge contusion ahead. News report ot cvidcnccby the National .Association of 1 Icalth Authorities and Trusts tothe I louse ot C^oninions inqtiiry into (.otntnunity C;\rc. NursingStandard l{\5/\()}, 7.

Armitage S. (1990) Liaison and Conlmuity oj Nursing Care: li.xeculiveSummary. Welsh OMicc, ('.ardilV.

Audit (^omniission (1991) 'I'he I Irtue of Patients: .Making the best useof Ward Nursing Resources. I IM.SO, London.

Audit Commission (19<)2) Lying in Wait: The use oj'.Medical Beds inAcute Hospitals. IIMSO, London.

Congdon J.G. (1990) Managing the incongruities: .An analysis olhospital discharge of the elderly. Communicating Nursing Research,

Nursing Research Transcending the 2l)th Century 23, 9 17.Curt-an I'., Gilmore D.l I. S: lieringer T.R.O. (1992) Cotnmunication

of tlischai-ge inlbrmation for elderly patients in hospital, 'flicUlster Medical Journal 61(1), S() SS.

Doll (l')89a) Caring jor People: Coniniiiiiity care in ibc next decade

and beyond. Department ot 1 Iealth, HMSO, London.r:)oll (l'),S9b) //(-(///// Circular 1IC(S9)5: Discharge of patients /rom

hospital. Department ot 1 Iealth, l lMSO, London.Doll (1992) The Patient's Cbarlcr CK. Department of Health,

HMSO, Lotidon.Hat-ding J. & Modell .\1. (l')S9) l-',lderly peoples" experiences of

dischai-ge IVotn hospital. Journal oj the Royal College oj GeneralPraclilloners 39, 17 20.

lackson .M.I'. (1990) Use of community support services by elderlypatietits discharged Irom getieral medical and geriatric wards.Journal if .Advanced Nursing \S, 167 175.

Klop R., van W'ijtiien I'.C.B. & Philipsen 11. (19')1) Patients' rightsand the admission atid discharge process. Journal of .-idvanccd

Nursing 16,408 412.Matnon j . , Steinwachs D.M., Fahey M., Bone L.R., Okray J. &

Klein L. (1992) Impact of hospital dischat-ge planning on meetingpatient needs after returi-iing hotne. Health Services Research 27

(2), 155 175.Meat-a J.R., Wood J.L., Wilson M.A. & Hat-t M.C. (1992) Home

IVotn hospital: .'\ survey ol hospital discharge arrangements inNorthamptonshire. Journal of Public Health .Medicine 14(2),145 150.

Naylor M.D. (1990) (xmiprchensive discharge planning tbr the

elderly. Re.warcb in Nursing and Health 1.̂ , M7- 347.

Skeet M. (1970) Home /rom Hospital: I be result oj a survey conducted

among recently discharged bospilal patients. Maemillan journalsLtd, London.

Victor C.R. (1991) Health and Health Care in Later Ltjc. OpenUniversity Press, Milton Keynes.

A'ietor C.R. & Vetter N.J. (1988) Preparing the elderly for dischargefrom hospital: A neglected aspect ot patient care? Igc and .Igcing17, 156 163.

Watei-s K. (1987) Outcomes of discharge from bospital for elderlypeople. 7«H/»((/ of .Idvanccd Nursing 12, 347 355.

Williatns V..\. & l'ittoti F. (1991) L se of nursing and social servicesby elderly patients discharged from hospital. Brilish Journal ofGeneral Practice 41, ~l-~/S.

Williams F,.l., Greenwell J. & Groom L.M. (1992) The care ofpeople over 75 years old after discharge from hospital: .\nevaluation of timetabled visiting by health visitor assistants.Journal of Public Healtb .Medicine 14(2), 138-144.