Comprehensive

Discharge Planning

&
Evidence
Based
Practice Presented by:
Jennifer R. Williams R.N.
What does the literature
reveal about the
utilization and
effectiveness of discharge
planning and the ethics
associated with the
process?
Discussion Points
n What the Evidence Presents

n Analysis of the Evidence

n Discussion and Experience

n Recommendations

n Overall Conclusion
 What does the evidence
present?
n Discharge planning is an essential part
of the discharge process.
n Discharge planning is an integral
process in acute care.
n Comprehensive discharge planning
improves the outcomes of patients post
discharge.
n Discharge planning often lacks
instruction on psychological and social
issues.
 Evidence cont…
n Having a designated discharge planner
or care manager, improves the
discharge process.
n It is important to incorporate all
disciplines into the planning process.
n Nurses are often not oriented
appropriately in discharge planning.
n Managed care puts limits and
constraints on nurses, causing ethical
dilemmas with discharge plans.
Analysis
of the
Evidence
 Research on
Comprehensive
Discharge
Planning of the
Hospitalized
Elderly
Problem
n To study the effects of a
comprehensive discharge planning
protocol.
Content of Research
n There were 276 patients and 125 caregivers included in
study.
n Patients were 70 years and older and alert and
oriented at time of discharge.
n Patients separated into four groups: Medical control
group, Surgical control group, Medical intervention
group, and Surgical intervention group.
n Patients were randomly assigned to intervention and
control groups.
n Medical diagnoses included: Congestive heart failure
and Myocardial infarction/Angina.
n Surgical diagnoses include: Coronary bypass graft and
cardiac valve replacement.
n Nurse specialists with master’s degrees in gerontology
nursing and a minimum of 1 year of practice
implemented the designed protocol for the intervention
groups.
n Standard discharge planning process utilized in the
control groups.
Data Collection
n Comprehensive physical assessments
and interview of patients at two, six,
and twelve weeks post discharge.
n Documentation of re-re-hospitalization for
both control and intervention groups.
n Calculation and cost comparison of re- re-
hospitalizations versus specialized in
home care as initiated with the
comprehensive discharge program.
Results
n Patients in the medical and
surgical intervention groups had
fewer readmissions, fewer total
days re-
re-hospitalized, lower
readmission charges, and lower
charges for out patient health care
services post discharge.
Interventions Affecting
Research Outcomes
n Comprehensive initial and ongoing assessment of the
discharge planning needs of the patient and his or her
caregiver.
n Development of a discharge plan with inclusion of all
disciplines involved with patient’s care.
n Improved and validated education of patient and
caregiver.
n Early initiation of discharge planning during
hospitalization and continuation of plan through two
weeks post-
post-discharge.
n Improved interdisciplinary communication regarding
patient’s discharge status.
n Ongoing evaluation of the effectiveness of the discharge
plan during and after discharge.
Limitations of Research

n Study performed in an urban

setting.
n Most patients were well educated
with good support systems and
minimal functional deficits.
Further Study
Recommendations
n Study should be replicated with elderly
patients admitted from various settings,
including nursing home.
n Study should include patients with
cognitive and functional deficits and
limited support systems.
n Additional diagnosis along with various
geographical areas should also be
included in future studies.
 Analysis of the Research
Findings

n Comprehensive discharge planning

improved outcome of patients.
n Improved intervention = More cost
effective.
n Interdisciplinary cooperation assists in
improved discharge plan.
n Intensive follow up after discharge
needed to improve patient outcomes.
Conclusion

n Implementing a comprehensive
discharge plan early in a patient’s
hospitalization, including needed
disciplines in the process, and increased
utilization of follow up services after
discharge improves patient’s long term
outcomes and decreases medical costs.
Research on
Discharge
Planning as
Part of the
Daily Nursing
Process
Problem
n Discharge planning efforts within
increasingly focused environments
and competing priorities.
Content of Research
n Study conducted in 32-
32-bed surgical unit.
n Seven women undergoing total abdominal
hysterectomies were included in the study.
n Patients ages ranged from 36-36-70 years.
n Eight RNs working full or part time were also
included in the study.
n Nurses ages ranged from 22-22-37 years with
professional experience of 1 month to 17 years
with at least an associate nursing degree.
Data Collection
n Participant observation conducted
to capture nurse-
nurse-patient
interaction and unit activities.
n Informal and formal interviews
conducted with all of the
informants.
n Review of all relevant unit
resources and polices along with
patient’s medical records.
Results
n Deficits were
found in both
documentation 47

of discharge 46.5

46

planning 45.5

45

implementation 44.5
North

as well as nursing 44

43.5

reliance on the 43

42.5

“typical patient” 42
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

for guidelines of
the discharge
plan.
Problems Affecting Adequate
planning
n Nurses under time constraints.
n Nurses focused on physical recovery and
not psychosocial or social needs.
n Discharge plan not personalized to
patients.
n Bulk of planning performed on the day
of discharge.
n Discharge planning that was completed
was not documented appropriately.
Research Limitations
n Use of a small population of both
patients and nurses.
n Data collected on day shift only.
n Gender of patients were all
female.
n Variable patient-
patient-nursing
assignments disrupted continuity
of care.
 Analysis of Research Findings

n Patient assignments interfere with

proper and comprehensive discharge
planning.
n Appropriate documentation is difficult
to complete under time constraints.
n Poor outcomes of patients focuses on
the need for coordination of care.
n Discharge planning is a complex and
nursing--intensive work and needs to be
nursing
recognized as such.
Conclusion

n Recognition of discharge planning

as a complex and nursing-
nursing-intensive
work is imperative in the attempt
to incorporate this process into day
to day nursing or to convince
organizations of the need for a
designated discharge planner.
Research on Ethical
Dilemmas Among
Nurses as They
Transition to
Hospital Case
Management.
Part 1&2
Problem

n The exploration of ethical concerns

of clinical nurses as they transition
into hospital case management.
Content of Research
n Fifteen nurse case managers were included in
the study.
n Subjects were collected from acute hospitals,
military hospitals, non-
non-profit hospitals, and
teaching hospitals.
n Subjects were involved in either discharge
planning, case management, or utilization
review activities.
Data Collection
n Each nurse was interviewed.
n In
In--depth interviews averaging 1-
1-1.5
hours were utilized.
n Interviews were audio taped then
transcribed.
n Data was interpreted using Max
van Manen’s method of thematic
analysis.
Results
n In adequate orientation to case
management for beginning case
managers.
n Obligations to organization affects
ability to advocate for patients.
n Managed care often affects
adequate and thorough discharge
planning.
 Ethical Issues Identified in
Findings

n Organization instruction affects

initiating appropriate services for
patient realities.
n Insurance policies and need for cost
containment decrease the planner’s
ability to provide advocacy, autonomy,
and appropriate patient needs at
discharge.
n Perceived inadequate planning and
organizational funding affects proper
orientation and education of case
managers.
Research Limitations

n Study limited to 15 participants.

n Performed only in the mid-
mid-
Atlantic region of the United
States.
n Not all health care settings
utilized.
n Ethical dilemma research limited
to case management process.
Further Study
Recommendations
n Include more geographical areas.
n Investigate additional health care
settings to include emergency,
home health, hospice, etc..
n Include different ethnic
backgrounds of patients cared for
by the case managers.
Analysis of Research
n Nurse case managers experience frequent
ethical concerns.
n Rules and regulations often conflict with
nurses’ own professional judgment.
n Limited knowledge affects appropriate
quality nurse management.
n Case managers have difficulties overcoming
obstacles affecting their obligations to
patients.
n Policy change and system reform may be
needed to overcome difficulties with patient
advocacy.
Conclusion
n The conflicts in values related to patient
safety, advocacy, and professional opinion is a
difficult ethical battle that case managers
often encounter.
n Lack of organizational resources leave
discharge planners distressed, helpless,
powerless, and frustrated.
n Lack of appropriate orientation in
combination with ethical concerns can cause a
lack of adequate patient plans during
hospitalization and post discharge, making
many case managers uncomfortable with the
decisions they make.
Discussion
and
Experience
Lets Discuss…
n The difficulties nurses often face focusing on
patients and discharge needs.
n The lack of appropriate discharge planning
that is common in hospitals without a
designated discharge planning department.
n The incorporation of other disciplines into
discharge planning.
n The ethical issues that play a large role in the
discharge planners’ ability to plan
appropriately for the patient.
n The researches expression that discharge
planning is an essential part of the discharge
process despite frequent poor construction.
 My Personal
Experience and
Observation as a
Discharge Planner
and Continuing
Care Coordinator
Personal Experience

n I have been involved with discharge

planning for two years.
n I am an RN currently preparing for my
BSN degree.
n I have been a nurse for almost ten years
and have worked in multiple areas of
nursing.
 Difficulties That I Often
Encounter in Discharge
Planning
n As a discharge planner it is my job to educate,
facilitate, communicate, and integrate
information appropriately to complete a
personalized discharge plan for each patient.
n Taking the time to get individuals to discuss
their issues is a very important factor, although
often time consuming and difficult.
n It is challenging at times to deal with
uncooperative and noncompliant patients or
families.
n It is often a struggle in my position to manage
the cooperation of all disciplines involved in a
patient’s care.
Difficulties cont…
n Managed care and budget constraints often
put a limit on the abilities I have as a
discharge planner.
n I often struggle with the short hospital stays
and time constraints put on me during the
planning process.
n Lack of funding at the facility, in which I work,
makes it difficult to stay updated on current
discharge planning practices.
n It is important for me to do my best both
professionally and ethically to plan for the best
possible outcomes for my patients.
Recommendations for
Evidenced Based Practice
n Implementation of comprehensive
discharge planning is supported in
this research.
n Health care organizations should h
designated a nurse discharge
planner or department.
n Existing discharge planning areas
should be evaluated for
effectiveness.
 Suggestions for New Planning
Implementations
n Inclusion of all disciplines during
planning process with a suggestion for
implementation of daily multi-
multi-
disciplinary meetings and recording of
the findings.
n Improved education for families and
patients with early introduction of
discharge planning and support of the
plan from all disciplines.
n Improved orientation, education, and
continuing education programs for
discharge planners and case managers.
 Conclusion of Research
Evidence and Use in
Evidenced Based Practice
ü The literature reveals that discharge
planning is not always an effective
process.
ü Managed care, time constraints, short
stay hospitalization, and ethical issues
all contribute to discharge planning
issues.
ü Implementation of this evidence based
practice into the field of discharge
planning would be successful in
improving patient outcomes and the
reputation of this important process.
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