Table 4

The consensus framework for an effective discharge planning system
Theme 1: Initial screening & assessment Remarks
Initial screening:
1a: An initial risk screening should be performed within 24 h after admission to differentiate patients with simple or complex discharge planning needs. Modified
1b: HARRPE (Hospital Admissions Risk Reduction Program for the elderly) is one of the screening tools which could be used to identify a proportion of elderly aged 60 or above with a higher risk of hospital readmission. Modified
1c: A patient with score of above 0.2 is considered as high risk and requires a complex discharge arrangement.
The following items should be included in the initial assessment for all patients to serve as flags to trigger discharge planning as appropriate:
1d: Social support – living alone, day time alone, night time alone, with maid, with spouse, with children, with grandchildren, with others.
1e: Care support – Yes (by spouse, son, daughter-in-law, daughter, son-in-law, grandchildren, maid, others), No
1f: Any change of ADL on admission compared with pre-morbid state before this admission e.g. change of Barthel Index if Modified
1g: Functional ambulatory category (modified): lyer, sitter, dependent walker, assisted walker, supervised walker, indoor walker,
outdoor walker (independent, assisted with carer, assisted with equipment)
1h: History of fall risk for the past one year: No history of fall, history of fall = 1, recurrent falls, present to medical attention for fall, both risk factors are present
1i: Mental state: normal, disorientated, disturbed, poor memory, not communicate
1j: Medications: good drug compliance, poor drug compliance
Theme 2: Discharge planning process including ongoing clinical and functional assessment to facilitate the development of care plan and final discharge plan
2a: The four main dimensions for assessment should include medical health, physical, psychological and social functioning.
2b: Care plan should be initiated within 24 h after admission. Modified
2c: Three categories of discharge plans could be developed based on the complexity of patients and assessment of their needs:
- Generic discharge plan suitable for simple case
- Disease-based discharge plan suitable for complex cases when there are disease specific protocols
- Non-disease specific, but tailored, discharge plan for complex cases identifying either by HARRPE or by assessment
2d: Ongoing assessment/evaluation should be conducted throughout the episode of care to review and update the conditions of patients.
2e: Effective and accessible IT 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 (priority for high risk groups). Modified
Theme 3: Coordination of discharge - continuing and timely process from hospital stay to discharge
3a: A designated person e.g. a designated doctor, nurse, or allied health professional should be notionally responsible for ensuring that all aspects of discharge planning have been addressed by the time of discharge.
3b: The role and responsibility of different healthcare professionals for the different tasks in the discharge planning process should be clarified. Newly added
3c: Once the patient is identified to have complex care needs, the designated person should initiate discharge planning with a multidisciplinary approach.
3d: Case conference should be considered as one of the options 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. Modified
3e: The suitability of discharge destination e.g. whether home or old-aged home, should be assessed to ascertain whether the support required is available.
3f: Referral/arrangement for social support services should be initiated once the patient is assessed to have post discharge support need in the community.
3g: Formal mechanisms for information transfer to community services providers for continuity of care should be established. Modified
3h: Prompt provision of essential community equipment including walking aids, wheelchairs, low vision or hearing aids, safety alarm, urinal, blood pressure machines, glucometers, visual door etc. should be facilitated before discharge. Modified
3i: Appropriate education and training should be provided to patients/carers to ensure that they understand how to use the equipment.
3j: Appropriate information and education on medication management including side effects of medication should be provided to patients/carers before discharge.
Theme 4: Implementation of discharge
4a: Patients and/or carers should be engaged in the preparation of the discharge process.
4b: Appropriate information on their illness should be given to the patients/carers to ensure that they could manage their ongoing care after discharge.
4c: Patients/carers should be informed of any danger signals they should be aware of before discharge.
4d: A specifically designed patient discharge summary including clinical diagnosis, follow-up and investigation appointments, medication and nursing care and instructions for allied health and social support services, should be given to patients/carers upon discharge. Modified
4e: If the patient has complex care needs/disease specific problem, a contact information should be provided on who to contact if they are concerned about their condition or treatment after discharge.
4f: Discharge summaries with necessary information should be issued to the facilities or care providers e.g. old aged homes within 48 h of discharge.
4g: Discharge summaries with necessary information should be issued to the Hospital Authority outpatient and day care services within a week of discharge.
4h: Timely transport arrangement for discharged patients should be made if necessary. Modified
4i: Timely transport arrangements when attending outpatient appointments should be made if necessary.
4j: A “Patient Checklist” should be completed before discharge to ensure that they understand the discharge plan and their needs are addressed. Modified
Theme 5: Post discharge follow up
5a: If the patient has complex care needs and is transferred from an acute hospital to a rehabilitation hospital, verbal communication via telephone or written information about the patient’s conditions should be made between the healthcare professionals in acute and rehabilitation hospitals. -
5b: If the patient is referred to disease specific or special discharge programmes, person-to-person communication or written information about the patient’s conditions should be made between different parties.

Yam et al.

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

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