3. CAPÍTULO III ANÁLISIS SITUACIONAL
3.1. LA EMPRESA
3.1.9. DESCRIPCIÓN DE FUNCIONES DEL AREA DE PLANIFICACIÓN:
Locating hospital discharge
Hospital discharge describes the point at which inpatient hospital care ends, with ongoing care transferred to other primary, community or domestic environments. Reflecting this, hospital discharge is not anend point, but rather one of multiple transitions within the patient’s care journey.14,48The organisation and
provision of thistransitional caretypically involves multiple health and social care actors, who need to co-ordinate their specialist activities so that patients receive integrated and, importantly, safe care. The inherent complexity of co-ordinating a large number of actors, often based in distinct organisations, leads to the view that hospital discharge can be a vulnerable, time-dependent and high-risk episode in the patient pathway.
A prominent example of this complexity is‘delayed discharge’, where the patient remains in hospital because of the failure to appropriately co-ordinate care between agencies.27,48According to Victoret al.,49
nearly 30% of older people experience some delay in their hospital discharge, which is known to expose patients to additional hospital-related risks, create emotional and physical dependency, incur additional hospital costs and restrict the availability of inpatient beds. In parallel, premature discharge or discharge without appropriate arrangements for onward care can also lead to complications for patient recovery. For example, the 28-day readmission rate for older people has doubled from 103,000 in 2001–2 to 201,000 in 2010–11,50,51suggesting that more needs to be done to support patient recovery following
acute care.
The problems of delayed or poorly planned discharge illustrate the broader challenge of integrating health and social care.27Analysing the causes of these delays, Tierneyet al.31point to a range of common factors,
including (a) poor communication between health and social care; (b) lack of assessment and planning for discharge; (c) inadequate notice of discharge; (d) inadequate involvement of patient and family; (e) over-reliance on informal care; and (f) lack of attention to the special needs of vulnerable groups. Reflecting this and other evidence,27policies have repeatedly sought to improve discharge planning,
especially the integration of health and social care agencies. A review of these initiatives is outlined below. Discharge planning
Improved‘discharge planning’has been a consistent recommendation of policy and research.27,52–54
health and social care reforms, changing economic imperatives and emerging concerns about care quality.55–58Furthermore, they have been developed both locally, by individual care organisations, and
nationally, for example by the NHS Institute for Innovation and Improvement, and there is no commonly agreed model. Despite efforts to promote discharge planning, the recent European HANDOVER study found that health-care professions still did not prioritise discharge planning or interagency communication as supporting enhanced discharge.59In 2010, the Department of Health published its new discharge
workbook,Ready to Go? Planning the Discharge and Transfer of Patients from Hospital and Intermediate Care,30which outlined 10‘steps’to ensuring a timely, safe and patient-centred transition from
hospital, including:
l effective communication with individuals and across settings
l alignment of services to ensure continuity of care
l efficient systems and processes to support discharge and care transfer
l clear clinical discharge management plans
l early identification of discharge or transfer date
l identified named lead co-ordinators
l organisational review and audit
l 7-days-a-week proactive discharge planning.
Effective discharge planning is usually associated with a number of common activities and procedures along the care pathway:14,30
l On admission Prepare detailed and accurate patient record; review assessment information and estimate date of discharge with reference to standard care pathway and complexity of
patient circumstances.
l During admission Undertake regular multidisciplinary assessment of patient condition to identify and assess opportunity for discharge; discuss with patient and family ongoing and continuing needs.
l At least 48 hours prior to discharge Inform MDT about estimated date of discharge and review assessment criteria; initiate referrals to community health-care providers and social care agencies; contact agencies responsible for ordering and/or installing patient equipment or home modification; social work/care assessment and referrals; complete referral for social care; finalise care package; order take-home medicines; arrange transport.
l Day of discharge Contact family and carers to confirm follow-up care arrangements; check documentation completion; issue discharge letter to general practitioner (GP); reinforce patient behaviour recommendations and rehabilitation; confirm and finalise transport.
l Follow-up care Initiate social care package and continuing health-care package, where relevant in consultation with GP.
As these policies suggest, a number of specialist roles and activities are promoted as supporting the integration of different agencies. A longstanding objective has been to promote the use of MDTs in discharge planning.14,53These are normally organised as formal, usually weekly, meetings between
relevant health and social care specialists with the aim of supporting timely communication, inclusive decision-making and continuity of care. Research often describes MDTs as comprising a core team including the named doctor and nurse, occupational therapists (OTs) and physiotherapists (PTs), and representatives from community and social care agencies, as well as family representatives, GPs and other specialist therapists. According to Bull and Roberts,52MDTs help break down barriers between professional
groups and foster a sense of common purpose and trust. Importantly, MDTs provide an opportunity for communication, first between professionals, second with patient and family, and third with community health-care providers. Furthermore, MDTs can help make clear the lines of responsibility for different tasks and create opportunities for individuals to take the lead in co-ordinating the planning process. In practice, however, convening all representatives for individual patients can be challenging in terms of time
A further initiative has been the introduction ofdischarge co-ordinators.14,30These are individuals, usually
experienced nurses, who take lead responsibility for both strategic planning and co-ordination of discharge at the interorganisational level.60Research suggests that discharge co-ordinators can improve hospital
discharge through supporting the integration of different professionals, overseeing and directing planning and addressing emergent problems in a more responsive way.61In particular, co-ordinators acquire both
deeper understanding ofandextended relationships with a wider range of care agencies that help them better navigate and align divergent ways of working that usually delay or undermine discharge.52,61,62
Integrating care services
In line with the developments in discharge planning, policies have also introduced new or extended statutory powers, financial opportunities and penalties to support more integrated discharge pathways. For example, the Health Act 199963enabled health and social care agencies to pool resources to codeliver
rehabilitation services. Similarly, in 2005, delayed discharge grants were made available to social service authorities across England to develop reablement services. In contrast, the Community Care (Delayed Discharges) Act (CCDDA) 200364addressed the problems of integration by allowing
hospitals to claim financial reimbursements from local authorities where they delayed discharge by not providing timely services. Against this backdrop, a variety of integrated services and new care pathways have emerged to support the transition from hospital to community, but in doing so have extended (and made more complicated) the range of services involved in discharge planning.
One significant development has been the introduction of ESD. ESD is often associated with the care and rehabilitation of mild-to-moderate stroke patients. It enables patients to return home early with a
dedicated package of rehabilitation and reablement of a similar intensity to that provided by inpatient care. ESD is shown to reduce the burden on acute providers and support patient recovery.65The funding of
ESD through joint commissioning between the acute NHS providers, GPs, social services and central government highlights the role of joint working and resource pooling, but there remain variations across the UK, especially in rural areas, where a lack of funding can limit provision.66,67
Intermediate servicesprovide transitional,‘step-down’care between acute hospital and the domestic environment (usually for 30 days). Patients are typically declared as‘medically fit’but requiring ongoing care or rehabilitation, for example those at risk of readmission or with complex care needs. Rather than receiving rehabilitation at home or in hospital, intermediate care offers a form of residential, hospital-like care, but with a focus on rehabilitation. Research suggests that intermediate care services have been effective in both reducing financial costs and improving patient outcomes.68Owing to their close proximity
to patients’homes and relatives, community (NHS) hospitals or nursing homes are often used for
intermediate and post-discharge rehabilitation. Stays in such units can be longer than in other intermediate care services, yet research suggests patient outcomes are generally favourable.69The recent Cochrane
reviews of long-term rehabilitation in care homes show no evidence of negative health outcomes.65,70
A similar initiative is the introduction ofreablementservices. These usually involve a dedicated package of social care to support daily living in the immediate period following discharge (e.g. personal care, cooking and cleaning). They are usually managed and provided by local authority social services, although in some cases they are funded through both health and social care budgets. In 2012, the Department of Health allocated £150M for reablement linked to hospital discharge,30to be allocated through primary care
commissioners working in partnership with social care authorities. Significantly, these services are normally arranged and provided by social services to ease transition from hospital for a period of 4–6 weeks, with the expectation that ongoing social care will be reassessed and provided by other agencies.
A further example of service innovation, with particular reference to end-of-life care, is the introduction of
‘fast-track’discharges. This normally relates to supporting early discharges from hospital for those patients wishing to spend the last days of life in the community with palliative support. This end-of-life discharge can exemplify effective joint working and rapid prioritisation, whereby the patient can be discharged within 48 hours with all specialist support and medications in place.71For example, funding decisions are
established post discharge to remove delays; the needs of the patient and family are met by deliberate use of a continuous dialogue with one specialist co-ordinator; and the emphasis is on timely collaborative working to ensure the patient gets home as requested.72
The threats to‘safe discharge’
Multiple sources of evidence suggest that care quality can be suboptimal in, or as a consequence of, hospital discharge.28In a major telephone survey of 400 patients following discharge, Forsteret al.17
found that nearly 20% reported some form of adverse event, of which 6% were preventable and 6% ameliorable. Research highlights a number of common discharge-related risks associated, for example, with the management of medicines, the provision of appropriate health and social care, incomplete tests and scans, the fitting and use of home adaptation, and the risks of falls, infections or sores.17–28
The underlying sources of these risks can range from factors related to the patient’s condition or
comorbidities, to the assessment of patient need, the availability of specialist resources in the community, and wider organisational and cultural factors. For example, research shows that the patient’s condition, such as hip fracture, and other comorbidities, especially cognitive function and fragility, can represent a cluster of risks, particularly for older patients, that can complicate the discharge process.73,74Research also
suggests that time of day, week or year can also have an impact on discharge planning and quality. In particular, discharges during the weekend have been shown to increase the likelihood of death compared with those taking place between Tuesday and Friday, accounting for 34% of all post-discharge deaths.75,76
Although studies highlight the importance of clinical risk in discharge planning, it is not always clear how
‘risk’is measured. Moreover, the causal analysis of risk is often implicit or an emergent feature of wider trial research. Reviewing the recent literature (Table 1), a number of risks (direct threats to safety) and identified causes (suggested or inferred) are catalogued.
Although the sources of these risks can be complex and variable, research frequently highlights incomplete, inaccurate and inaccessible information as undermining collaborative workings and
contributing to unsafe patient discharge.27–29,86,87A systematic review conducted by Kripalaniet al.29found
that communication between hospital and family doctor was often partial or missing, relying primarily upon discharge summaries which were often incomplete, lacking in detail and not provided in a timely manner. Similarly, poor communication between the hospital and social care providers is a long-standing risk factor in adverse events.27,29,88There remains little extensive research, however, examining the causes
of poor communication and adverse events.29,89Less is known about how communication breakdowns and
patient safety are experienced by patients and carers.54A number of studies propose, and in some cases
evaluate, interventions to support communication and information transfer at discharge, including structured communication tools, discharge planning guides, discharge checklists, medicine reconciliation guides and patient education strategies.84,90–94These suggest that effective discharge planning depends
upon effective communication and collaboration between health and social care agencies.28,86,95In his
analysis of the factors that support or hinder such communication and collaboration, Glasby27highlights
three dimensions:
l occupational factorsrelated to the particular knowledge, cultures and practices of different professionals
l organisational factorsrelated to the working patterns, capabilities and resources of different agencies
l compatibility and co-ordinating factorsrelated to how occupational and organisational factors are aligned, or differences reconciled.
Attention to these and other factors is needed to better understand and enhance communication and collaboration in discharge planning and care transition. Furthermore, greater appreciation is needed of how communication might undermine not only co-ordination but, in turn, safety. In this sense,
communication might be seen as a latent (or active) factor that influences the safety of hospital discharge. The next section develops this idea through relevant theory and research on organisational complexity and safety.