A Simple Plan
Discharge planning
improves the odds

By Jane Erwin
Illustration: William Jacoby
June 28, 1999

For many patients, getting ready to leave the hospital is one of the most critical aspects of their hospital stay. Recent studies have shown that careful discharge planning, along with good follow-up contact, can significantly improve patients’ health upon discharge while decreasing healthcare and social costs.

Proper planning for departure from the hospital can make all the difference in patients’ long-term prognosis because it encourages them to get involved in managing their own care, said Patricia T. Castiglia, PhD, RN, FAAN, a pediatric nurse practitioner and dean and professor of nursing at the University of Texas at El Paso College of Nursing and Health Services. “With discharge planning, patients can maintain a level of health and improve it,” Castiglia said. “It also helps people assume more responsibility for their own health.”

APN study

A recent report in the Journal of the American Medical Association outlined the effectiveness of a special discharge plan for hospitalized elderly patients with serious illnesses. The program, directed by Mary Naylor, PhD, of the University of Pennsylvania in Philadelphia, was devised and carried out primarily by nurse practitioners and clinical nurse specialists who all had at least two years’ experience in gerontology. They focused on medication, symptom management, diet, activity, sleep, medical follow-up, and the emotional status of patients and their caregivers. “We targeted both the patients and their caregivers from the point of admission,” Naylor said. “Our protocol was derived based on state-of-the-science needs of elders.”

The APNs visited patients during hospital stays and at least twice at home after discharge. The nurses were available for more home visits as needed, and they called the patients weekly and were available by phone seven days a week.

“The feedback has been overwhelming and very gratifying,” Naylor said. “One thing we’ve learned is that discharge planning requires the clinical acumen and the expertise of an APN to coordinate resources [for patients].”

By 24 weeks after discharge, only 20 percent of the group on the special discharge plan had been rehospitalized, compared with 37 percent of a similar control group. The intervention group also had fewer hospital days and about half the total health services costs as the control group.

Nursing, social work

Advanced practice nurses and other healthcare providers play a big role in discharge planning because patients are going home sooner and sicker due to the pressures of the managed care environment. “There’s less time for educating them and for follow-up and reinforcement,” Castiglia said. “Materials are sent home with the patient, but that doesn’t mean they are read or understood.”
Along with advanced knowledge and preparation in clinical practice, many APNs have counseling, education, and organizational experience, which makes them suited to the intensive patient and caregiver contact needed in discharge planning, Castiglia said.
At the DuPont Hospital for Children in Wilmington, Del., a nurse practitioner is part of the hospital’s discharge planning team. However, a social worker coordinates the planning teams, said Edward Woomer, MSW, director of social work at DuPont.
DuPont’s discharge planning teams also include a floor nurse, a physician, and sometimes others, depending on the patient’s needs, which can range from financial assistance for medication to physical therapy referrals, Woomer said. DuPont’s discharge planning staff developed a quality assurance study to look at delays in patient discharges, Woomer said. “Those who leave the hospital on time do so due to the intervention of a lot of people,” he said.

AIDS plan

Discharge planning can be especially important for HIV-positive patients and for those who have developed full-blown AIDS.
Volunteers do the discharge planning at the New York-based AIDS in Prison Project/HIV Information Hotline, where peer educators help those who have been incarcerated plan for life outside.
Risk factors for their patient base include no health insurance or source of income, homelessness, no prior regular health care, active substance abuse, psychiatric diagnoses, neurologic or cognitive deficits, a history of noncompliance with healthcare or social service arrangements, and no support system. The program provides short-term case management and assists with housing, medical appointments, and educational and vocational counseling.

“I think we’re successful because we do what needs to be done,” said Ruben Rodriguez, hotline supervisor. “We want to get people on their feet as quickly as possible.”