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Prevent Readmissions With Discharge Planning

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   April 05, 2011

Discharge planning is a process that should begin as soon as patients are admitted to the hospital. In a perfect world, healthcare team members, patients, and families communicate and work together to move patients quickly and safely to home or the next level of care.

In reality, discharge planning can be fractious. Older adult patients and their families face many choices about where to go and often disagree on the best course of care. Communication among caregivers can be far from ideal and communication between patients and families can be fraught with disagreements.

As hospitals battle readmission rates, more attention is being paid to discharge planning. Lori Popejoy, Phd, APRN, GCNS-BC, assistant professor in the Sinclair School of Nursing at the University of Missouri, has been studying the discharge planning process around older adults and recommends hospitals pay more attention to the decision-making process with these patients. 

Popejoy, who has years of experience with care of the older adult before entering academia, recently published a study, “Complexity of Family Caregiving and Discharge Planning,” in the Journal of Family Nursing. I spoke to her about the problems nurses face as they work with older adults and their families, the challenges faced by healthcare providers as they discharge older adults from the hospital, and the healthcare transitions faced by elderly people and their families following hospitalizations.

Popejoy says that our understanding of discharge planning and how patients make decisions is quite simplistic. We usually think about conversations between physicians and their patients or between physicians and families. In reality, dozens of people are involved in any decision. So she examined interactions between healthcare team members, including nurses and social workers, and older adult patients and their families. She wanted to understand how these diverse stakeholders come together to make a single decision about leaving the hospital and where they are going to go. She wanted to understand how much participation in decisions patients and families want the healthcare team to have and what actually happens as decisions unfold.

“Every participant comes to the situation with their own values, their own beliefs, and what they want to get out of it,” says Popejoy. “What stands out for nurses or social workers is their overall concern for patient safety. Their input into the decision making process is to find the most reasonable choice and the safest choice.”

For older patients, most just want to go home. Some recognized they were too weak and were willing to go somewhere else, but for them, it was to be a short-term stay where they could get stronger and then ultimately go home.

For families, safety is important, but also the issue of ‘I want my parent to be able to live the life they want to live,’ says Popejoy. “For a spouse, it’s a whole different ball game—they just want their spouse to go home with them.”

Within child-parent relationships, some want their parents to live with them; others recognize that their lives are too complicated to handle a parent at home who is functionally unable to care for themselves. Some can handle a short-term stay, but not one for the long term.

Popejoy says that hospitals need to figure out who the key players are who can influence decisions. “Listen to older adults and find out what they want, but also listen to the family and what they can do,” she says.

She cautions decision makers are often not available during Monday to Friday business hours. Although most organizations know this, it can be difficult to get good information across the week, not just during traditional work days. Discharge planning and communication may have to be done via conference calls or during off hours.

Another important thing that leaves healthcare teams in difficult positions is the idea of autonomy.

“In the United States, we value autonomy and your independence above all else,” says Popejoy. “But if you really think about it, my independence may impede upon your independence. If an older adult says ‘I’m going home no matter what and you have to live with it.’ And the child says ‘I can’t handle it right now,’ that older adult has the right to make that decision. The child also has the right not to participate.”

Hospitals are stuck in the middle, but have to support both sides. Hospitals also must look at the spouse and appraise the situation. If the main caregiver is a 5-foot 1-inch, 100-pound woman, how will she be able to lift her 230-pound debilitated spouse?

It’s important to consider what will happen because such situations lead to subpar, degenerating care that end up in readmission.

Popejoy concedes she doesn’t have the solutions, but that hospitals need to consider their options. She says when hospitals return patients to the community, it’s often a complicated process of care coordination to find sources to help older adults manage at home.

“Hospitals are not well placed to do that,” says Popejoy. Patients are admitted for relatively short times and it’s difficult to discover intricacies of living and family arrangements in a short time. “But hospitals will have to get better at partnering with different community organizations and performing solid handoffs and communicating with patients and families to build solid plans that work, otherwise patients end up back in the hospital,” she says.

Home health keeps patients for an average of two weeks. “That’s about the amount of time they are starting to become unstable again,” she says

She said hospitals must be realistic about discharge plans. Is the plan simply to get the patient out of the hospital? Or is the plan to get them out and keep them out? Hospitals are paying the biggest price for readmissions, but it will take even more effort to solve the problem.

When discharging older adults, hospitals must consider the situation at home and whether the family will be willing to follow a care regimen. Identify the problems and the organizations that can help. Popejoy also recommends a different approach to patient education and concentrating on what patients really need to know.

“We think they need to know all about how to take care of their drains,” she says. “And yes, that’s important, but we also need to know what’s most frightening to patients and what will be their stumbling block.” Issues such as where do they go for help? Do they understand the warning symptoms that could put them in jeopardy of readmission?

Such planning requires thought from healthcare teams and doesn’t lend itself to following a predetermined path.

“I get how hard this is,” says Popejoy, “I’ve done this for years myself before I went into academics.”

As the baby boomers age, the influx of older adults will stretch already thin resources and make aggressively tailoring discharge plans to individual patients a greater priority.


Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at

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