Table 2

Clarity, Validity and Applicability of those 11 sentences which do not reach consensus
No. Statement % of respondents rated 4–5 on a 5-point scale
Clarity Validity Applicability
Theme 1: Initial screening
1a An initial risk screening should be performed within 24 h after admission to identify those patients with high risk of admission and have complex discharge planning, required to provide ongoing care and additional support after leaving hospital. 96 88 42
1b HARRPE (Hospital Admissions Risk Reduction Program for the elderly), a screening tool developed by HA, could be used to stratify those elderly aged 60 or above with a higher risk of hospital readmission. 96 67 79
1f The following items should be included in the initial assessment for all patients to serve as flags to trigger discharge planning as appropriate: Any change of ADL: ADL Barthel Index before admission, and on admission (declining ADL index) 83 88 67
Theme 2: Discharge planning process: including ongoing clinical and functional assessment to facilitate the development of care plan and final discharge plan
2b Care plan should be performed within 24 h after admission. 92 71 29
2e Systems for the accurate and timely communication of assessment and associated care planning information across clinical disciplines and settings should be developed and implemented to enhance care continuity. 88 100 71
Theme 3: Coordination of discharge: continuing and timely process from hospital stay to discharge
3c Case conference should be considered for high risk patients for better communication between team members in the multidisciplinary team and to enable seamless and timely transition from hospital to community. 88 83 71
3f Formal mechanisms for information transfer across clinical and social settings e.g. through discharge summary should be adopted rather than solely relying on informal communication between health and social professionals. 92 92 67
3g Prompt provision of all community equipment including walking aids, wheelchairs, low vision or hearing aids, safety alarm, urinal, blood pressure machines, glucometers, visual door etc. should be ensured before discharge. 88 83 46
Theme 4: Implementation of discharge
4d A patient copy of discharge summary and/or nursing discharge summary should be given to patients/carers on the date of discharge. 100 83 63
4h When transport is to be used, this should be booked at least 24 h, where feasible, in advance of discharge. 96 96 67
4j A “Patient Checklist” should be completed by the patient or carers before discharge to ensure that they understand the discharge plan and their needs are addressed. 100 92 58

Yam et al.

Yam et al. BMC Health Services Research 2012 12:396   doi:10.1186/1472-6963-12-396

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