This chapter describes the general themes, principles and goals of patient discharge planning. The aim is to establish ‘best practice’ in discharge planning following all types of surgery, through reference to policy documents, research findings and the use of clinical scenarios. Age alone is a poor predictor of postoperative recovery and rehabilitation to pre-hospitalization lifestyle. However, older people are more likely than other groups of patients to live alone, suffer from chronic illness or be cared for by others who are themselves advanced in years. They are, therefore, particularly vulnerable within the discharge planning process (Department of Health, 1989 and Department of Health, 2001a) and their particular needs are emphasized in this chapter.

The importance of effective discharge planning is recognized within Government policy documents, e.g. The National Service Framework for Older People (DoH, 2001b), Your Guide to the NHS – Getting the Most from Your NHS (DoH, 2001c) and Changing Places: Report on the Work of the Health and Social Care Change Agent Team 2002/03 (DoH, 2003a). These documents highlight the need for collaborative interprofessional working, using the single assessment process and patient-centred care concept.

The Government introduced a system of reimbursement for hospital discharge in April 2004. Implementing this system required best practice home discharge and interprofessional partnerships. Discharge from Hospital: Pathway, Process and Practice (DoH, 2003b), an updated and extended version of the Hospital Discharge Workbook (DoH, 1994), contains detailed and definitive guidance, and examples of good practice in all facets of hospital discharge.

Research spanning some 30 years (Skeet, 1970, Victor and Vetter, 1984, Nazarko, 1997, Nazarko, 1998 and Munshi et al., 2002) has suggested that patients discharged from hospital often fail to receive the care they need, and this can result in readmission, which is costly for the patient, the family and the National Health Service (Townsend et al., 1988 and Vetter, 2003). Failure in discharge planning has been attributed to:

The impetus to improve discharge planning has never been greater. Through advances in technology, potentially life-enhancing surgery is possible for an increasingly older population. Simultaneously, pressure on acute hospital beds and Government policy emphasizing care delivery within a community setting (Department of Health, 1990, Department of Health, 1997, Department of Health, 1998, Department of Health, 2001a and Department of Health, 2003a) has encouraged rapid patient discharge. The Department of Health (2003a) claims that about 60% of all people that are in acute hospitals waiting for care arrangements to be organized as inpatients are over 65 years of age. It warns that the acute setting is not conducive to adequate rehabilitation while waiting for care arrangements to be organized. This could lead to patient institutionalization and increased susceptibility to hospital-acquired infections such as MRSA. Severing important links with the older person’s care networks may occur if the process is too drawn out. The Community Care (Delayed Discharges etc.) Act (DoH, 2003c) enables trusts to be penalized for such delays. Paradoxically, just as the need for thorough and efficient discharge planning is heightened by surgical interventions on increasingly vulnerable individuals, the available time in which to achieve this is reduced (Audit Commission, 1999).

Discharge planning has been described as:

Discharge planning is an actively managed process, usually starting at the preassessment clinic or the point of admission (Hurst, 1996 and Rudd and Smith, 2002), with agreed pathways of care (DoH, 2003a). The process should identify patients who are likely to need actively managed transfers and ongoing health and social care services at the point of their admission, or as near to admission as possible.

Communication among the members of the multidisciplinary team (MDT), e.g. general practitioner (GP), hospital nurse, district nurse, discharge coordinator, occupational therapist, social worker, in partnership with the patient and carers, when community plans are being set up is vital (Salter, 2002). Nurses in the acute hospital setting and in the community should act as the receivers and completers of discharge checklists, and ensure that a number of different services are in place prior to patient discharge (Audit Commission, 1992, Department of Health, 1994 and Department of Health, 2003b). For example, occupational therapists assess patients’ ability to cope within their home environment after treatment for the most common trauma conditions such as humeral and hip fractures (Rudd and Smith, 2002). Dietitians can offer advice and information on dietary modification. Provision of ‘social care’ within the community following discharge may fall within the remit of social services; hence, the social worker’s involvement in discharge planning. Assessing social needs may be of greater importance for older patients, as some authors have claimed that this group are likely to require a higher level of care prior to admission (Nixon et al, 1998). The GP’s or community matron’s early involvement in discharge planning can reduce the likelihood of readmission and shows better outcomes for the frail older person (Department of Health, 2004 and McInnes et al., 1999, cited in Munshi et al, 2002). The evolving role of the discharge liaison nurse to coordinate hospital and community services has been criticized because it reinforces barriers between hospital and community staff, who subsequently may relinquish responsibility for their role in patient discharge (Audit Commission, 1999).

The process of discharge planning, therefore, has a number of different phases (King and MacMillan, 1993 and Mamon et al., 1992). These phases are:

Victor and Vetter (1988) state that adequate notice of discharge, discussion of arrangements for aftercare with patient and family, arrangements for aftercare and liaison with primary care services are the key elements of discharge planning. A joint policy statement by the British Geriatrics Society, the Association of Directors of Social Services and the Royal College of Nursing (1988) recommended that, at discharge, a patient should have the following:

The same document recommends that an identified discharge coordinator should lead and record communication with all relevant agencies, and that the goals of discharge planning should be patient-oriented and set by the patient in association with the multidisciplinary team.

Discharge planning takes place within the context of Government policy. This emphasizes the centrality of ‘primary care’ (DoH, 1998) and the growing importance of care delivery within a community setting. Certain key legislation has directly influenced patient discharge planning. The National Health Service and Community Care Act (DoH, 1990), which was enacted in 1993, divided the responsibility for provision of statutory health services between three main agencies: local authorities, health authorities and the Family Health Services Authority. Henceforth, local authorities were given responsibility for making annual agreement with their related health authorities, on the purchasing of residential and nursing home care and on arrangements for discharging patients from hospital into the community. Statutory recognition was given to the division between ‘health’ and ‘social’ care, with responsibility for provision of the latter falling to local authorities.

The split between health and social needs and between purchasers and providers of care, which was created by The National Health Service and Community Care Act (DoH, 1990), has been accused of increasing fragmentation of care (Benton, 1995) rather than enhancing the ‘seamless’ garment envisaged by Griffiths (DHSS, 1988). If patients are assessed, at their discharge from hospital, as having a ‘social’ rather than a ‘health’ need, then it is the direct responsibility of the social services department of the local authority to meet that need. However, differences of opinion may exist between professional groups as to what constitutes a ‘health’ need or a ‘social’ need, respectively. A social worker, for example, may consider the hygiene needs of a post-surgical patient discharged into the community for palliative care to be a ‘health’ need. For the community nurse, on the other hand, that patient’s need for pain relief is a health need, but his bed-bath is ‘social’. Finite resources within social services departments can mean that needs are assessed according to the availability of care provision rather than as dictated by patients and their professional and non-professional carers. Tierney (1993) described the legislation as creating ‘artificial boundaries’ between hitherto closely related agencies. Within this scenario, patients, particularly those with complex needs, are likely to be transferred between agencies (Klop et al, 1991) or to disappear into the dividing void.

In 1989, the Department of Health issued guidelines on planning for discharge of patients from hospital, which recognized this potential for fragmentation. Financial penalties were threatened for those trusts lacking appropriate mechanisms by which to provide ‘shared care’ between health and social services, and a Hospital Discharge PlanningWorkbook (DoH, 1994) was devised as a guide to practice. Although nurses were to have a central role in the assessment of health needs, no one profession was allocated the key role of ‘discharge coordinator’. Victor and Vetter (1988) saw this as an omission and recommended the appointment of a key professional to coordinate discharge planning. Exemplars of good practice (Bradbury, 1997) certainly suggest that a coordinator improves the efficiency of discharge planning for all concerned.

Delays in discharge were commonly blamed on insufficient capacity within local residential and nursing homes. The Government advised that more intermediary care resourcing was required to allow rehabilitation and promote independence, such as community hospital beds (DoH, 2003a).

Communication problems were a recurrent theme within descriptions of poor discharge planning. Tierney (1993) found that even within one type of institution (hospitals) there were examples of communication breakdown. Professionals were unsure as to whether or not decisions should be made by the multidisciplinary team, or if they were the responsibility of individuals. Communication between hospital and community were even more problematic. Victor (1991) found that contributions from community staff to discharge planning were limited and that while some health professionals were recognized as having a legitimate role within the discharge planning process and were therefore invited to participate, others were not given this recognition and remained outside the process. Staff from nursing homes may well fall within this second category and, although they will inevitably provide post-discharge care, may find themselves excluded from planning arrangements.

The Department of Health’s revised and updated version of The Discharge Workbook (DoH, 2003b) includes the need for a named discharge coordinator and to have interdisciplinary teamwork in the decision-making process. This is to ensure that:

Nursing staff perceptions of current discharge planning procedures are not well documented (Nixon et al, 1998). The authors cite Tierney’s study (1993), which found practical issues such as ambulance/transport problems and prescription/pharmacy issues, as well as the already noted communication problems among health and social care professionals. These included the discharge notice being too short, failed provision of services, delay in discharge letters and poor communication with social work and occupational therapy departments. The updated workbook (DoH, 2003b) may help to create a more effective system.

The Audit Commission, 1992 and Audit Commission, 2000 found that perspectives of patient need varied between nurses within the acute sector and those in the community. Whereas hospital-based nurses had difficulty in predicting patient needs within the home environment, community nurses found difficulty in understanding the concept of the ‘named nurse’. Audits to measure the effectiveness of discharge management and planning can help staff reflect on the issues involved in the process and increase staff cooperation (Rudd and Smith, 2002).

To examine recommendations for best practice in discharge planning, each phase will now be discussed in more detail.

In her early work, Roberts (1975) rightly claimed that discharge planning, by its very nature, implied some deficit in an individual’s self-caring ability. Assessment of health need is the first step in estimating the extent of, and ultimately making good, that self-care deficit. Assessment is the foundation of all good discharge planning.

The National Health Service and Community Care Act (DoH, 1990) emphasized the position of the nurse as the lead assessor of patient-vulnerable groups, which the DoH circular on discharge planning indicated were likely to be elderly people, those living alone, those with chronic illness and those with elderly or infirm carers (DoH, 1989).

Assessment, like the entire discharge planning process, should start early. If possible, assessment should begin before admission (DoH, 2002) and certainly before the point of discharge (Waters, 1987). Guidelines on preadmission discharge assessment have been issued by the Health and Social Services Department in conjunction with the Health Boards in Scotland (Scottish Office Home and Health Department (SOHHD), 1993), and the success of preadmission clinics throughout the United Kingdom has been well documented (Hurst, 1996). Evidence suggests that such clinics offer patients the opportunity to discuss worries and fears related to surgery, and offer professionals the opportunity to assess patients before the trauma of surgical intervention.

The patient’s perspective, and that of their family, should be at the very core of assessment (Department of Health, 1992 and Scottish Office Home and Health Department, 1993), with the professional helping the patient to overcome any initial reluctance to become involved (Waterworth and Luker, 1990 and Wiffin, 1995). The benefits of patient participation in discharge planning have been well documented. These include both improved clinical outcomes (Titler and Petite, 1994), and increased patient efficacy in post-discharge self-care (Hall and Carty, 1993). Social, environmental and emotional needs must be included within the discharge assessment; an assessment of physical needs alone will not suffice. What Cass (1978) called a ‘social diagnosis’ is an inherent part of any discharge plan, and this can only be achieved if adequate information is documented regarding living conditions and support at home. However, evidence suggests that information of this type is rarely recorded within the acute setting (King and MacMillan, 1993).

The single assessment process introduced in the care of older people (DoH, 2003a), contained within the edicts of the National Service Framework for Older People (DoH, 2001b), provides guidance as to the depth and scale of assessment according to individual needs of the patient and carer, including a risk assessment.

Older people, in particular, often find certain tasks they managed easily before surgery more difficult following a period of hospitalization (Bowling and Betts, 1984, Victor and Vetter, 1988 and Waters, 1987), and, to account for this, assessment must be dynamic and responsive to individual circumstances and needs. Moreover, although patients may cope well within the controlled hospital environment, they may find coping at home more difficult. Tierney et al (1994) (cited in Nixon et al, 1998) found that for both GPs and community nursing staff, post-discharge assessment was more common. Occupational therapists have a key role in assessing patient-coping potential within a number of different environments and informing the decisions of the multidisciplinary team.

Current nursing practice promotes the importance of the partnership between nurses and older people, using a biographical person-centred assessment of an individual’s potential and aspirations (Kings Fund, 1997). Therefore, using so-called objective standardized tools provides the healthcare professional with a dilemma. Furthermore, although multidisciplinary assessment is essential to good discharge planning, problems arise when different disciplines assess the patient from professional perspectives and/or use different assessment ‘tools’ or instruments (Banks, 1995 and Seedhouse, 1998). Frankum et al (1995) found that even when professionals use the same assessment tools, they often use them differently, according to their individual professional backgrounds, training and education. A variety of formal tools certainly exist, and it has been recommended that diverse tools are used in a variety of combinations to ensure a comprehensive and meaningful patient assessment (Royal College of Physicians and the British Geriatrics Society, 1992).

Recommended assessment tools include the Barthel Activities of Daily Living Index (the Barthel Index) (Mahoney and Barthel, 1965). The Barthel Index covers areas such as feeding, mobility from bed to chair, personal toilet, getting on and off the toilet, bathing, walking on a level surface, going up and down stairs, dressing and incontinence. Designed originally for use with long-term hospital patients, the Barthel Index needs modification to include social activities such as shopping and cooking and to accommodate more environmental influences on individual well-being (Ross and Bower, 1995).