PPN Week 10: Care Transitions, Discharge planning and system Navigation

Discharge planning defined

• A process used to decide what a patient needs for a smooth move from one level of care to another

• The doctor authorizes the patient’s release, but the actual process of discharge planning may be completed by a social worker, a discharge planner, or a nurse

Why is discharge so important? (Goldman et al, 2016)

• Focus on minimising length of stay at the hospital, ensuring safe and high-quality discharge experience and reducing unnecessary re-admissions

• Length of stay is linked to organizational imperatives concerning patient flow

• Aims to optimize bed availability, lessen emergency room wait times, and reduce costs

When does discharge planning start?

At admission. It is never to early to start strategizing this part healing process

Nursing role in discharge planning

Teaching patients about their condition, medications, self care strategies, and the importance of follow up care

• help patients maintain optimal level of health and reduce the chance of readmission

Is one of the most important duties a nurse has

Study purpose (An exploration of the tensions related to interprofessional collab in acute-care discharge planning) (Goldman et al 2016)

• To elicit a more in depth understanding of intrerprofessional interactions in discharge by using two sociological perspectives to understand the interplay of structural factors and microlevel practices

• patient discharge is a key concept in hospitals particularly in acute care given the complicated and multifaceted care needs

• Sample- patients on a general medicine unit in Canada

Study background (An exploration of the tensions related to interprofessional collab in acute-care discharge planning) (Goldman et al 2016)

• Planning and implementation of patient discharge is complex process involving multiple HCP but driven by competing health, political and economic factors

• policies on hospital discharge have identified the importance of inter professional collaboration but there are limitations with teamwork, communication, collaboration in the clinical context

• A major theme in previous studies on discharge is lack of charity of roles of the various members of the inter professional team and who does what in relation to discharge

Looking at discharge from a sociological perspective

Sociological theories of medical dominance and negotiated order provide macrolevel structural factors and microlevel interprofessional interactions

Negotiated order (Looking at discharge from sociological perspective)

• Understanding the process of interaction amongst healthcare providers by focusing on how social order in health care contexts is negotiated

• The continual working out together of who is to do what, how and with whom

Study findings (An exploration of the tensions related to interprofessional collab in acute-care discharge planning) (Goldman et al 2016)

• There is an existence of a medically dominant approach to patient discharge and opportunities for interprofessional negotiations within this broader structure

• Role of organizational routines in facilitating and challenging interprofessional negotiations in patient discharge

• Competing organizational priorities and the implications for an interprofessional approach to discharge

Discharge process (An exploration of the tensions related to interprofessional collab in acute-care discharge planning) (Goldman et al 2016)

• Hospital discharge policy outlined physicians’ authoritative role in discharge

• Policy indicated that physicians were responsible for discharge, but the decision making should occur in collaboration with the interprofessional team

Discharge process- Looking at interprofessional perspective (Goldman et al, 2016)

• Social workers: Discharge planning always took precedence over other role

• Physiotherapists and occupational therapists: assessment of a patient being physically and cognitively ready to be discharged from the hospital

• Pharmacists: medication reconciliation

• Nurse managers: not involved

• Ambiguity re: bedside nurse’s role

Competing organizational priorities and negotiations - Challenges​ (Study findings Goldman et al, 2016)

• Physicians explained that their decision making was effected by other professional responsibilities and hospital policies that could introduce tensions

• Challenges in timing of discharge and a lack of negotiation

• Limited physician to nurse interaction

• Pressures to address organizational expectations concerning patient safety and patient flow

Main ideas to point out (An exploration of the tensions related to interprofessional collab in acute-care discharge planning) (Goldman et al 2016)

• Need to explore medical dominance not as a binary issue

• Pressure for nurses to free up beds

• Move beyond “descriptive” teamwork evaluations to recognize the key professional, social and political issues

Study background (the integral role of caregivers in a patients transition home from medical unit Hahn-goldman et al,2018)

• Admission to hospitals for acute illness is difficult

• Patients are given a lot of information throughout their hospital stay and instructions at discharge

• The study was undertaken to explore factors impacting the ability of patients to understand and adhere to instructions

• Sample- 27 patients being discharged from a 3 academic acute care settings in ontario,canada

Study findings (the integral role of caregivers in a patients transition home from medical unit Hahn-goldman et al,2018)

• Participants had an overall high level of caregiver support

• Just over half of the participants reported high level of caregiver participation while discharge instructions were being given

• Patients who had high caregiver participation reported higher satisfaction scores

How caregivers are involved (the integral role of caregivers in a patients transition home from medical unit Hahn-goldman et al,2018)

• Providing care and assistance: Actively doing tasks for the patient including including medical tasks such as wound care and giving medication and daily living tasks such as driving and cooking

• Advocating for patient: standing up for patient, questioning doctor decisions or requesting additional resources

• Enacting vigilance: watching over patient for adverse reactions

• Being a source of comfort: Being with the patient provides a comfortable environment

• Acting as a translator

Outcomes of caregiver involvement (the integral role of caregivers in a patients transition home from medical unit Hahn-goldman et al,2018)

• Helped patients understand and adhere to their discharge instructions

• Were a source of reference

• Increased the patient’s ability to adhere to their discharge instructions- follow-up appointments

• Patients without informal caregivers had a hard time getting to follow- up appointments and noted poor experiences with their post discharge

Influencing factors impacting caregiver involvement (the integral role of caregivers in a patients transition home from medical unit Hahn-goldman et al,2018)

• Including caregivers when teaching discharge

• Providing something in clear writing

• Providing instructions earlier in the hospital stay

Main points of study (the integral role of caregivers in a patients transition home from medical unit Hahn-goldman et al,2018)

• Provides insight to HCPs to effectively identify targeted ways to involve caregivers during transitions

• Specific post discharge activities caregivers undertake include:

  • Emotional support

  • Medical care including medication administration

  • Homemaking and meal preparation

  • Transport to follow-up appointments

  • Advocacy and care coordination

Articles purpose (Mediators of marginalisation in discharge planning with older adults Durocger et al. 2017)

• Little research on discursive or other structural mediators

• To explore discharge planning from the perspective of older adults, family members and HCP to examine social and political influences affecting perspectives and practices with discharge planning with older adults

• Also wanted to explore how older adults’ agency may be mediated in discharge planning decision-making by social and political influences

• five case studies comprised of 22 participants interviews including 5 older adults, 7 family members and 8 HCPs

Themes (Mediators of marginalisation in discharge planning with older adults Durocger et al. 2017)

Underlying beliefs, valued approaches, and conventional practices

Underlying beliefs: Inevitable decline with age and professional expertise (Mediators of marginalisation in discharge planning with older adults Durocger et al. 2017)

Two prominent underlying beliefs:

• Assumption that ageing was necessarily linked to a decline in agency and participation in decision making

• HCPs confidence in the superiority of their knowledge and expertise

Valued Approaches (Mediators of marginalisation in discharge planning with older adults Durocger et al. 2017)

• HCPs adhered to the principles of client centred care

• Client preferences were described as distinct from and subordinate to the first objective of client safety

• “I advocate for what the patient wants as long as it is safe”

Conventions and practices: The discharge planning family conferences (Mediators of marginalisation in discharge planning with older adults Durocger et al. 2017)

• HCPs described the family conference as a time to engage older adults and their families in discharge

• The process of the conferences followed a standard format

• Although goals were set in collaboration with older adults, they reflected the HCPs instructions more so than older adults’ aims

• Older adults and family members felt the meeting helped by providing information, but more information would be required at a later point

• Discharge decisions were made by professionals; older adults and their families were expected to comply

What were the challenges (Mediators of marginalisation in discharge planning with older adults Durocger et al. 2017)

• Discharge planning processes and individual behaviours were influenced by dominant discourses that link ageing to expected loss of agency

• Underlying beliefs about professional expertise and conventional practices influenced discharged practices