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Issues and Strategies > Hospital Discharge Planning: A Guide for Families and Caregivers E-mail to a Friend Printable Version Family Caregiver Alliance

A trip to the hospital can be an intimidating event for patients and their families. As a caregiver, you are focused completely on your family member's medical treatment, and so is the hospital staff. You might no be giving much thought to what happens when your relative leaves the hospital.

Yet, the way this transition is handledwhether the discharge is to home, a rehabilitation ("rehab") facilit or a nursing homeis critical to the health and well-being of your loved one. Studies have found that improvements in hospital discharge planning can dramatically improve the outcome for patients as they move to the next level of care. Patients, family caregivers and healthcare providers all play roles in maintaining a patient's health after discharge. And although it's a significant part of the overall care plan, there is a surprising lack of consistency in both the process and quality of discharge planning across the healthcare system.

This Fact Sheet will look at the keys to a successful transition from hospital to home, explain some important elements, offer suggestions for improving the process, and provide caregivers with checklists to help ensure the best care for a loved one. If you are a caregiver, you play an essential role in this discharge process: you are the advocate for the patient and for yourself.

What is discharge planning?

Medicare says discharge planning is "A process used to decide what a patient needs for a smooth move fro one level of care to another." Only a doctor can authorize a patient's release from the hospital, but the actu process of discharge planning can be completed by a social worker, nurse, case manager or other person. Ideally, and especially for the most complicated medical conditions, discharge planning is done with a tea approach. In general, the basics of a discharge plan are:

Evaluation of the patient by qualified personnel Discussion with the patient or his representative Planning for homecoming or transfer to another care facility Determining if caregiver training or other support is needed Referrals to home care agency and/or appropriate support organizations in the community Arranging for follow-up appointments or tests.

The discussion needs to include the physical condition of your family member both before and after hospitalization; details of the types of care that will be needed; and whether discharge will be to a facility

home. It also should include information on whether the patient's condition is likely to improve; what activities he or she might need help with; information on medications and diet; what extra equipment migh be needed, such as a wheelchair, commode, or oxygen; who will handle meal preparation, transportation a chores; and possibly referral to home care services.

Why is good discharge planning so important?

Effective discharge planning can decrease the chances that your relative is readmitted to the hospital, help recovery, ensure medications are prescribed and given correctly, and adequately prepare you to take over your loved one's care. Not all hospitals are successful in this. Although both the American Medical Association and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) offer recommendations for discharge planning, there is no universally utilized system in US hospitals. Additionally, patients are released from hospitals "quicker and sicker" than in the past, making it even more critical to arrange for good care after release.

Studies have shown that as many as 40 percent of patients over 65 had medication errors after leaving the hospital, and 18 percent of Medicare patients discharged from a hospital are readmitted within 30 days. Th is not good for the patient, not good for the hospital, and not good for the financing agency, whether it's Medicare, private insurance, or your own funds. On the other hand, research has shown that excellent planning and good follow-up can improve patients' health, reduce readmissions and decrease healthcare costs.

Even simple measures help immensely. For example, you should have a telephone number(s) accessible 2 hours a day including weekends, for care information. A follow-up appointment to see the doctor should b arranged before your loved one leaves the hospital. Since errors with medications are frequent and potentially dangerous, a thorough review of all medications should be an essential part of discharge planning. Medications need to be "reconciled," that is, the pre-hospitalization medications compared with the post-discharge list to see that there are no duplications, omissions or harmful side effects.

Under the best of circumstances, the discharge planner should begin his or her evaluation when the patient admitted to the hospital.

The caregiver's role in the discharge process

The discharge staff will not be familiar with all aspects of your relative's situation. As caregiver, you are th "expert" in your loved one's history. While you may not be a medical expert, if you've been a caregiver for long time, you certainly know a lot about the patient and about your own abilities to provide care and a saf home setting.

The discharge planners should discuss with you your willingness and ability to provide care. You may hav physical, financial or other limitations that affect your caregiving capabilities. You may have other obligations such as a job or childcare that impact the time you have available. It is extremely important to

tell hospital discharge staff about those limitations.

Some of the care your loved one needs might be quite complicated. It is essential that you get any training you need in special care techniques, such as wound, feeding tube or catheter care, procedures for a ventilator, or transferring someone from bed to chair.

If your loved one has memory problems caused by Alzheimer's disease, stroke, or another disorder, discharge planning becomes more complicated, and you will need to be a part of all discharge discussions You may need to remind the staff about special care and communication techniques needed by your loved one. Even without impaired memory, older people often have hearing or vision problems or are disoriente when they are in the hospital so that these conversations are difficult to comprehend. They need your help

If you or your family member are more comfortable speaking in a language other than English, an interpreter is needed for this discussion on discharge. Written materials must be provided in your language as well. Studies have shown that numerous, and sometimes dangerous, errors can be made in home care when language is not taken into account at discharge.

Because people are in a hurry to leave the hospital or facility, it's easy to forget what to ask. We suggest yo keep the questions on pages 5-6 with you, and request that the discharge planner take the time to review them with you.

Getting help at home

Listed below are common care responsibilities you may be handling for your family member after he or sh returns home:

Personal care: bathing, eating, dressing, toileting Household care: cooking, cleaning, laundry, shopping Healthcare: medication management, physician's appointments, physical therapy, wound treatmen injections, medical equipment and techniques Emotional care: companionship, meaningful activities, conversation.

Community organizations can help with services such as transportation, meals, support groups, counseling and possibly a break from your care responsibilities to allow you to rest and take care of yourself. Finding those services can take some time and several phone calls. The discharge planner should be familiar with these community supports, but if not, your local senior center or a private case manager might be helpful. (See the Resources section at the end of this Fact Sheet.) Family and friends also might assist you with home care.

If you need to hire paid in-home help, you have some decisions to make. Unfortunately, these hiring decisions are often made in a hurry during hospital discharge. You might be handed a list of agencies, with instructions to decide which to usebut often without further information. This is another good reason discharge planning should start earlyas caregiver, you'll have time to research your options while your loved one is cared for in the hospital. Think about both your needs as a caregiver and the needs of the person you are caring for, including

language and cultural background.

You have a choice between hiring an individual directly or going through a home care or home health care agency. Part of that decision may be affected by whether the help will be "medically necessary" i.e., prescribed by the doctor, and therefore paid for by Medicare, Medicaid or other insurance. In that case, the will most likely determine the agency you use. In making your decisions, consider the following: home ca agencies take care of all the paperwork for taxes and salary, substitutes will be available if the worker is sick, and you may have access to a broader range of skills. On the other hand, there may be a more person relationship if you hire an individual directly, and the cost is likely to be lower. In either case, try to get recommendations for hiring from acquaintances, nurses, social workers and others familiar with your situation.

Discharge to a facility

If the patient is being discharged to a rehab facility or nursing home, effective transition planning should ensure continuity of care, clarify the current state of the patient's health and capabilities, review medicatio and help you select the facility to which your loved one is to be released.

Too often, however, choosing a facility can be a source of stress for families. You may have very little tim and little information on which to base your decision. You might simply be given a list of facilities, and asked to choose one. To help, a private geriatric care manager (for whom you will pay an hourly fee) or a social worker can offer much needed advice and support. There are also online sources of information (see the Resources section of this Fact Sheet) that rate nursing homes, for example.

Convenience is a factoryou need to be able to easily get to the facilitybut the quality of care is very important, and you may have to sacrifice your convenience for the sake of better care. The list of question on pages 5-6 will give you direction as you start your search for a facility.

Paying for care after discharge

You might not be aware that insurance, including Medicare, does not pay for all services after a patient ha been discharged from the hospital. However, if something is determined by the doctor to be "medically necessary" you may be able to get coverage for certain skilled care or equipment. You will need to check directly with the hospital, your insurer or Medicare to find out what might be covered and what you will have to pay for. Keep careful records of your conversations.

What if you feel it's too early for discharge?

If you don't agree that your loved one is ready for discharge, you have the right to appeal the decision. Yo first step is to talk with the physician and discharge planner and express your reservations. If that isn't enough, you will need to contact Medicare, Medicaid or your insurance company. Formal appeals are handled through designated Quality Improvement Organizations (see the Resources section). You should

know that if the QIO rules against you, you will be required to pay for the additional hospital care. The hospital must let you know the steps to take to get the case reviewed.

Improving the system

As we have mentioned throughout this Fact Sheet, discharge planning is an inconsistent process which varies from hospital to hospital. Who does it, when it's done, how it's done, what kind of follow-up is mandated, and whether caregivers are assessed for their ability to provide care and included as respected members of the discussion are all elements that differ from setting to setting.

In general, hospitals make money only when beds are occupied, so in many cases, discharge and transition care planning become "orphan" services that produce no revenue. Despite its benefits, which clearly increase the well-being of patients and caregivers, discharge/transition planning is often not given the attention it deserves, and indeed, ineffectual planning often serves to add to patients' and caregivers' stress

Discussions among experts on improving transitional care and discharge planning have centered on improvements that emphasize education and training, preventive care and including caregivers as member of the healthcare team. Some studies have revealed that surprisingly simple steps can help. For example, sending the summary of care to the patient's regular doctor increases the likelihood of effective follow-up care. Likewise, telephone calls from knowledgeable professionals to patients and caregivers within two da after discharge help anticipate problems and improve care at home. Broader recommended changes in practice and policy include:

Formally recognize the role families and other unpaid caregivers play, include them as part of the healthcare team, and assess their capabilities and willingness to provide care. Coordinate care across sites, from hospital to facility to home. Improve communication between hospital and community-based services. Develop better educational materials, available in multiple languages, to help patients and caregive navigate care systems and understand the types of assistance that might be available to them, both during and after a hospital stay. Improve training for healthcare staff, including ways to respond to language, culture and literacy differences. Simplify and expand eligibility for public programs. Make transitional care a Medicare benefit; change reimbursement policies to cover more home-based care in addition to institutional care. Reward hospitals and physicians that improve patient well-being and reduce readmissions to hospitals.


Multiple studies have explored the importance of effective discharge planning and transitional care, and have highlighted the very real benefits in improved patient outcomes and lower rehospitalization rates. Several pilot programs have illustrated those benefits, but until healthcare financing systems are changed t support such innovations in care, they will remain unavailable to many people. Caregivers, patients and advocates are continuing their efforts to alter our healthcare system to make discharge planning a priority.

With our graying population, these changes are ever more necessary.

Some Basic Questions for Caregivers to Ask

Questions about the illness:
o o o o o o

What is it and what can I expect? What should I watch out for? Will we get home care and will a nurse or therapist come to our home to work with my relative? Who pays for this service? How do I get advice about care, danger signs, a phone number for someone to talk to, and follow-u medical appointments? Have I been given information either verbally or in writing that I understand and can refer to? Do we need special instructions because my relative has Alzheimer?s or memory loss?

What kind of care is needed?

o o o o o o o o o o o o o o o

Bathing Dressing Eating (are there diet restrictions, e.g., soft foods only? Certain foods not allowed?) Personal Hygiene Grooming Toileting Transfer (moving from bed to chair) Mobility (includes walking) Medications Managing symptoms (e.g., pain or nausea) Special equipment Coordinating the patient?s medical care Transportation Household chores Taking care of finances

Questions when my relative is being discharged to the home*

o o o o o o o o

Is the home clean, comfortable and safe, adequately heated/cooled, with space for any extra equipment? Are there stairs? Will we need a ramp, handrails, grab bars? Are hazards such as area rugs and electric cords out of the way? Will we need equipment such as hospital bed, shower chair, commode, oxygen tank? Where do I g this equipment? Who pays for these items? Will we need supplies such as adult diapers, disposable gloves, skin care items? Where do I get the items? Will insurance/Medicare/Medicaid pay for these?

Do I need to hire additional help?

Questions about training

o o o o o o

Are there special care techniques I need to learn for such things as changing dressings, helping someone swallow a pill, giving injections, using special equipment? Have I been trained in transfer skills and preventing falls? Do I know how to turn someone in bed so he or she doesn?t get bedsores? Who will train me? When will they train me? Can I begin the training in the hospital?

Questions when discharge is to a rehab facility or nursing home

o o o o o o o o o

How long is my relative expected to remain in the facility? Who will select the facility? Have I checked online resources such as for ratings? Is the facility clean, well kept, quiet, a comfortable temperature? Does the facility have experience working with families of my culture/language? Does the staff speak our language? Is the food culturally appropriate? Is the building safe (smoke detectors, sprinkler system, marked exits)? Is the location convenient? Do I have transportation to get there?

For longer stays:

o o o o o o o

How many staff are on duty at any given time? What is the staff turnover rate? Is there a social worker? Do residents have safe access to the outdoors? Are there special facilities/programs for dementia patients? Are there means for families to interact with staff? Is the staff welcoming to families?

Questions about medications

o o o o o o o o

Why is this medicine prescribed? How does it work? How long the will the medicine have to be taken? How will we know that the medicine is effective? Will this medicine interact with other medications?prescription and nonprescription? or herbal preparations that my relative is taking now? Should this medicine be taken with food? Are there any foods or beverages to avoid? Can this medicine be chewed, crushed, dissolved, or mixed with other medicines? What possible problems might I experience with the medicine? At what point should I report these problems? Will the insurance program pay for this medicine? Is there a less expensive alternative? Does the pharmacy provide special services such as home delivery, online refills or medication review and counseling?

Questions about follow-up care:*

o o o o o o

What health professionals will my family member need to see? Have these appointments been made? If not, whom should I call to make these appointments? Where will the appointment be? In an office, at home, somewhere else? What transportation arrangements need to be made? How will our regular doctor learn what happened in the hospital or rehab facility? Whom can I call with treatment questions? Is someone available 24 hours a day and on weekends?

Questions about finding help in the community:

o o o o

What agencies are available to help me with transportation or meals? What is adult day care and how do I find out about it? What public benefits is my relative eligible for, such as In-Home Supportive Services or VA services? Where do I start to look for such care?

Questions about my needs as a caregiver:*

o o o o o o o o

Will someone come to my home to do an assessment to see if we need home modifications? What services will help me care for myself? Does my family member require help at night and if so, how will I get enough sleep? Are there things that are scary or uncomfortable for me to do, e.g., changing a diaper? What medical conditions and limitations do I have that make providing this care difficult? Where can I find counseling and support groups? How can I get a leave from my job to provide care? How can I get a respite (break) from care responsibilities to take care of my own healthcare and other needs?

* Adapted with permission from, United Hospital Fund.

Next Step in Care. United Hospital Fund.

A Family Caregiver's Guide to Hospital Discharge Planning. National Alliance for Caregiving and the United Hospital Fund of New York. "Adverse Events after Hospital Discharge," Agency for Healthcare Research and Quality, Patient Safety Network.

"Discharge Process Reduces Hospital Use in the 30 Days Following Discharge," December 2007, Agency for Healthcare Research and Quality.

"Studies Suggest Ways to Improve the Hospital Discharge Process to Reduce Postdischarge Adverse Even and Rehospitalizations," December 2007, Agency for Healthcare Research and Quality.

"E.R. Patients Often Left Confused After Visits," Laurie Tarkan, New York Times, Sept. 16, 2008, "TipSheet for Beneficiaries-Hospital Discharge Planning," Center for Medicare Advocacy. Medicare: "Planning for Your Discharge" Publication 11376. Medicare: "Compare Care Home Health Brochure" Publication 11070.

Medicare: "Guide to Nursing Home Compare." "A Simple Plan Discharge Planning Improves the Odds," Jane Erwin, Nurseweek, June 28, 1999.

"Safety As You Go from Hospital to Home, A Consumer Fact Sheet." National Patient Safety Foundation From Hospital to Home: Improving Transitional Care for Older Adults, 2006, Health Research in Action, University of California, Berkeley.

Family Caregiver Alliance 785 Market Street, Suite 750 San Francisco, CA 94103 (415) 434-3388 (800) 445-8106 Web Site: E-mail: Family Caregiver Alliance (FCA) seeks to improve the quality of life for caregivers through education, services, research and advocacy. FCA's National Center on Caregiving offers information on current social, public policy and caregiving issues, provides assistance in the development of public and private programs for caregivers, and assists caregivers nationwide in locating resources in their communities. For residents of the greater San Francisco Bay Area, FCA provides direct family support services for caregivers of those with Alzheimer's disease, stroke, ALS, head injury, Parkinson's and other debilitating health conditions that strike adults. Family Care Navigatorsm Developed by Family Caregiver Alliance, a comprehensive online guide for caregivers to locate services and programs in all 50 states. Includes Frequently Asked Questions and glossary. FCA Fact Sheet: Hiring In-Home Help, FCA Fact Sheet: Caregivers Guide to Medications & Aging,

Next Step in Care United Hospital Fund Comprehensive information and advice to help family caregivers and healthcare providers plan transitions for patients. Spanish translations available. Medicare (800) MEDICARE Medicare: Planning for Your Discharge Publication 11376, Medicare's Nursing Home Compare Medicare Rights Center Center for Medicare Advocacy "Tip Sheet for Beneficiaries: Hospital Discharge Planning" Quality Improvement Organization, QIO Eldercare Locator (800) 677-1116 National Association of Geriatric Care Managers (520) 881-8008

What is it and how can it help me? Planning for discharge with clear dates and times reduces:

Patient's length of stay Emergency readmissions Pressure on hospital beds

This is true for all patients, both day surgery and patients who have more complex needs. When does it work best? With elective care, discharge planning should start before admission. This allows everyone to focus on a clear endpoint in the patient's care. It also reduces errors and unnecessary delays along the patient pathway. If inpatient beds are a bottleneck, reducing pressure on beds will increase throughput and therefore reduce referral to treatment times. How to use it There are some common key elements when planning for discharge, regardless of whether a patient is receiving emergency or elective (inpatient or day case) care. These are:

Specifying a date and / or time of discharge as early as possible Identifying whether a patient has simple (80 per cent of all patients) or complex discharge planning needs Identifying what these needs are and how they will be met Deciding the identifiable clinical criteria that the patient must meet for discharge

This guide focuses on the key elements of planning for elective discharge for simple discharges. (The approach is similar for day case and simple inpatient discharge.) This includes a summary outlining the approach for complex discharge plus the resource materials available. There is also a short description to help discharge planning following an emergency admission. Simple discharge (inpatient / day case) 1. Plan the date and time of discharge early Plan discharge at pre-operative assessment so that everyone, including patients and carers, know what needs to happen and when the patient will be discharged. It also means patients/carers know what arrangements they need to make to help the patient get back home. 'To achieve a high quality service, discharge planning in day surgery should begin before the adult or child is admitted to the unit.' Royal College of Nursing (discharge planning for day surgery). 2. Plan for patients to be discharged before the peak in admissions As with hotels, many hospitals find planning for a reasonable proportion of patients to leave the ward before 11.00 am helps to manage the total loading on beds. The impact of this is illustrated in the background' section. 3. Plan for discharge seven days per week Admission patterns often loosely follow the day of the week. This is also true of discharges, with a rush on Friday to clear beds for the weekends. However, few discharges actually take place over the weekend. This can cause problems, especially on Monday when there may be many admissions for inpatient elective care. A focus on planning for discharge' seven days a week helps to reduce bed pressures. This is also illustrated in the 'background' section. 4. Patients are discharged using a criteria based process There is a range of discharge planning tools and guidance available.

British Association of Day Surgery, 2002 Ready to go Home' (Discharge criteria: guidelines about the discharge process and the assessment of fitness for discharge). Discharge planning: day surgery information by the Royal College of Nursing. A framework that covers physical, psychological and social aspects of patient care. You can use it to develop guidelines for patient discharge following day surgery.

5. Co-ordinate and check everything is in place 48 hours before discharge to ensure that everything is ready

This includes checking 'take home' medications and transport (including transport being provided by family / friends). For longer stays of over 48 hours, the discharge planning checklist should be completed 48 hours prior to discharge. 6. Timely and accurate communication for discharge Discharge for patients with more complex needs About 20 per cent of patients have more complex needs and may need additional input from other professionals such as social workers, therapists etc. The involvement of additional people makes co-ordination and planning even more critical. Planning at the pre-operative stage or early on following admission will really help to reduce delays. Further information about discharge planning is available from the Health and Social Care Agent Team:

Moving people with dementia Guidance material on how to decide if someone is safe to transfer

Discharge following an emergency admission The same evidence applies for all discharges regardless of type of admission so planning for discharge should begin as early as possible following an emergency admission. Examples 'Criteria based discharge has allowed our nursing staff to be absolutely clear about what patients have to do before they go home, and this has got rid of the fear of discharging Mr X's(consultant) patients without his say so.' Examples of criteria for discharge used in well performing services for hip and knee replacement surgery include:

Independence in washing, dressing and mobility Safe negotiation of stairs if necessary A clean wound Eating and drinking Postoperative x-ray performed

'Delivering Quality and Value', NHS Institute for Innovation and Improvement Making plans to go home 'A day and time for your discharge home will be agreed in advance with you. This will allow you to plan ahead for your own discharge. The ward staff may indicate that you should be collected and accompanied by a friend or relative when you go home. It is

important that you plan this with your friends or relatives as soon as you know your discharge date. When you leave we will give you a limited supply of any medicines you may need and a discharge letter for you to take to your GP when you get home. Please leave your home address and contact number with a member of staff on the ward. If you are planning to stay somewhere else, please leave an address where you can be contacted.' Nuffield Orthopaedic Centre NHS Trust, patient information. What next? If bed constraints are a hospital wide problem, carry out a simple hourly flow diagnostic to look at patterns of admission and discharge. Additional resources Complex discharge: more information available from the Health and Social Care Change Agent Team including a range of case studies. British Association of Day Surgery, 2002 Ready to go Home' (Discharge criteria: guidelines about the discharge process and the assessment of fitness for discharge). A Positive Outlook: Good practice toolkit This toolkit provides best practice guidance to show what works in reducing the current levels of delayed discharge being experienced by adults and older people in mental health services. It focuses on the practical steps which can be taken to improve discharge. Background The emphasis on discharge planning really began as a focus on the few patients who stay in hospital for a long time after they are clinically ready for discharge (termed as bed blockers'). Discharge planning is a key part of the operational management of beds There is evidence that there have been, and still are, temporary mismatches in the demand and capacity of beds. This occurs when the total number of new admissions necessitates patient discharge so that their beds become available. The Emergency Services Collaborative identified this as one of the reasons why A&E departments fill. The hospital is, to all intents and purposes, gridlocked' until patients are discharged. The Department of Health developed the following illustration in its publication 'Achieving timely simple discharge from hospital; a toolkit for the multidisciplinary team'. 'The dotted line shows the extra beds needed in this hospital during the few hours when admissions outpaced discharges. The red line shows that moving even just 30 per cent of discharges ahead of admissions would reduce the maximum bed

requirement from 35 to a very short term peak of just 10 over the average required.' Therefore, planning discharges before the peak in admissions is an effective way to smooth the total demand for beds.

The same authors also illustrate the importance of continuous discharge throughout the week to reduce the variation in demand for beds. 'Many hospitals still try to manage weekend capacity by discharging large numbers of patients on a Friday. Discharges then slow to a trickle until Monday morning (or often Monday afternoon). This is not the most effective strategy. It often takes several days for the mismatch between admissions and discharges, built up over the weekend, to resolve, with predictable consequences in terms of pressure on beds.

The example below shows this.'

Good Bed Managment Evidence of the impact of discharge planning: The impact of discharge planning on readmission rates, length of stay, health outcomes and cost to patients and healthcare providers is uncertain. The authors found it difficult to assess the impact of the evidence and concluded that, although the impact of discharge planning may be slight, it is possible that even a small reduction in length of stay or readmission rate could free up capacity for subsequent admissions in a healthcare system where there is a shortage of acute hospital beds. Discharge planning from hospital to home.

Acknowledgements / sources Department of Health British Association of Day Surgery 'Delivering Quality and Value', NHS Institute for Innovation and Improvement
Key components of discharge planning

Discharge is a complicated process involving different phases and aspects of care. Recognition of the components of an effective discharge can facilitate organizations in designing care delivery and orienting staff to discharge planning [31]. The literature highlighted that an efficient discharge required a provision of timely and informative risk screening for high risk patients, commencement or preparation of a discharge plan upon admission, timely notification of community providers [13,32]. Our findings from international literatures identified the key components of discharge planning under 5 major themes: (i) initial screening and assessment, (ii) discharge planning process including ongoing clinical and functional assessment to facilitate the development of care plan and final discharge plan, (iii) coordination of discharge including continuing and timely process from hospital stay to discharge, (iv) implementation of discharge focusing on patient readiness, post discharge service availability, and arrangement check before discharge, and (v) post discharge follow up. This framework provides a basis for developing more specific discharge planning protocol or care pathway for different type of patients in different settings. In addition, our 3-stage approach in developing a discharge policy framework involved statements on collaboration/communication between different type of healthcare professionals, patients, carers, and community service provision. Hedges pointed out that this component of collaboration was important to facilitate the timely discharge from hospital [32].
Initial screening and assessment

The initial screening and assessment is important to differentiate patients with different risks and complexities in care needs for discharge planning. UK specified that discharge planning should be classified as simple or complex discharge at the point of patient admission [16]. With regard to the risk assessment tools, the validity of the statement on Using Hospital Admission Risk Reduction Program for the Elderly (HARRPE) [HARRPE has been

developed by the Hong Kong Hospital Authority for patients over the age of 60 on the basis of readmission risks which is a predictive modeling approach], a screening tool developed by HA, to stratify patients with a higher risk of hospital readmission in our study was only 67% which was below the 75% level of consensus. The main concern of the participants on this statement was that there are a number of ways to identify patients who are likely to be high risk for readmission, and therefore HARRPE might not be the only or the best instrument. Kings Fund has conducted a literature review of the risk screening tools to develop a casefinding algorithm for high risk patients. Threshold approach, clinical knowledge, and predictive modeling are found to be three principal techniques in predicting risk [33]. HARRPE uses the clinical data of patients to model the risk of prediction of readmission in patients aged 60 or above. It includes the basic 13 specific risk factors: age, gender, living situation, functional status, cognitive status, behavior pattern, mobility, sensory deficit, number of previous admission, number of previous admission through Accident & Emergency Department, active medical disease, drugs, and need of referral. However, it does not contain the functional, cognitive status and mobility factor due to the unavailability of this data in the clinical management electronic system. Thus, our framework has proposed seven other items such as social support, care support, activity of daily living, functional status, mobility status, mental status, and fall history to supplement the tool and these risk screening items were well accepted by the participants in the study. These seven-item will then be used in our next stage of study to apply and pilot in a hospital to confirm its applicability and practicability.
Timeliness of discharge planning

The literature highlighted the need for timely discharge planning in the discharge planning policy/guidelines [13,32]. To support timely and efficient discharge required provision of timely and informative risk screening for high risk patients, commencement or preparation of a discharge plan upon admission, timely notification of community providers including transport arrangement, and provision and transmission of a timely and informative discharge summary [11,32]. Collaboration between patient, carer, hospital staff and community services may well be required to facilitate the timely discharge from hospital [32]. The above component of timelines of discharge planning was included in most of the discharge policy/protocols. Timeliness of discharge planning, on the other hand, also served as the

performance indicators for an effective discharge planning [11]. However, the criteria of timeliness e.g. within 24 h or 48 h varied among guidelines. NHS Trust in UK had set a timeframe of 24 h of admission to conduct a full nursing assessment, while another trust did not fix a timeframe, but required it to be commenced at the earliest possible stage [34]. The differences in the timeliness component were partly due to the setting and manpower constraint in the hospitals. In Hong Kong, we also faced the same problems in setting a timeframe in completing different tasks of discharge planning since the healthcare professionals were concerned about the issue of tight manpower and busy schedule in fulfilling the requirements due to the high turnover rate and caseload in the acute ward [6]. Our findings provided a discharge planning guideline on the timeframe of different milestones which was agreed by the local experts which takes into account its validity and applicability in the local context. These included (i) screening to be performed within 24 h after admission, (ii) care plan to be initiated within 24 h after admission, (iii) social support services to be initiated right after assessment, (iv) prompt provision of essential community equipment to be facilitated before discharge, (v) timely transportation to be arranged, (vi) discharge summary to be issued to (a) patients/care providers upon discharge, (b) health facilities or care providers such as old age home within 48 h of discharge, and (c) outpatient clinics within a week of discharge. These guidelines will also be piloted in the hospital to confirm it applicability and practicability.
Role of different healthcare professionals in discharge planning

Regarding the concern of manpower management, the needs to clearly define roles and coordination of the team are also important components in a multidisciplinary approach [14,32]. Our study echoed this point by having a statement on The role and responsibility of different healthcare professionals for the different tasks in the discharge planning process should be clarified to be included in the framework after group discussion. This statement had a high level of validity and applicability (both 88%). Nearly all discharge planning policy/guidelines requires a designated person in coordinating discharge [13,14,32,34]. There are various models for the use of a single specialist to undertake discharge planning, for example, a discharge planner who has specialist knowledge and skills in discharge needs, community services and referrals; a patient care and/or admission coordinator who has specific responsibilities to improve communication and linkages between healthcare

providers; or a case manager who focuses on the patient from admission to discharge, and to ensure earliest possible timely discharge. In Hong Kong, there is a Integrated Care Model (ICM) including a linked nurse to coordinate the inpatient services such as the formulation of care plan for post discharge care based on the comprehensive risk and needs assessment, and a case manager for the provision/coordination of the delivery of ambulatory and community health services. This ICM programme only applies to a small number of patients identified by the HARRPE screening system. The effect of discharge planning are generally quite mixed due to the diversity of the target patients served and the different ways of organizing a discharge plan [35].
Communication in discharge planning

Our study findings suggested that communication between multidisciplinary team members, between hospital staff and community service providers, and between hospital staff and patients were vulnerable to breakdown. A formal communication mechanism, for example use of structured discharge summary and case conference was highlighted as formal communication options in the discharge planning guideline. Use of computer technology further facilitates the formal communication mechanism and it was highlighted in our findings but the confidentiality of data was a requirement [31]. Providing continuing education opportunities for hospital staff to acquire a better understanding of the multidisciplinary team members roles and community service provision might improve communication among multidisciplinary team and between hospital and community teams. In addition, open communication with and education for patients and family carers are crucial to successful and timely discharge planning [15,36]. Studies indicate that patient participation in discharge planning results in better health outcomes for patients and family carers following hospitalization and reduce avoidable readmissions [37,38].
A standardized guideline for an effective discharge planning

The 3-staged process in the development of a discharge planning framework will provide a standardized guideline for an effective discharge planning to be applied in a local context. It addresses the current practice and the problem of a lack of standardized protocol for the discharge process [6]. The process also provides insight and reference on the conditions and conduct which will facilitate successful completion of a consensus framework by experts.

Adopting a Delphi approach demonstrates the values of the method as a pre-test (before the clinical run) of the components and requirements of a discharge planning system taking into account the local context and system constraints, which would lead to improvements to its applicability and practicability. To confirm the applicability and practicability of this consensus framework for discharge planning system, the third stage of process of development of the discharge planning framework is to apply and pilot the framework in a hospital setting to evaluate its feasibility, applicability and also impact in hospital including satisfaction from both the perspectives of staff and patients.

A structured, systematic and coordinated system of hospital discharge system is required to facilitate the discharge process to ensure a smooth patient transition from the hospital to the community and improve patient health outcome in both clinical and social aspect. An effective discharge planning system benefits the hospital system with fewer unplanned readmissions, better quality of care and contributions to a better health care system. Our study is a 3-staged process to develop, pretest and pilot a discharge planning framework. This paper covers the second stage of the development of the framework, where we adopted a Delphi approach to pre-test its validity and attest to clarity, applicability and practicability of the requirement and components of discharge planning for all patients in the hospital system. In addition to adding the value to the existing research evidence, the findings provide a framework reference helping policymakers and hospital managers to facilitate the discharge planning process to improve the quality of care and decrease unnecessary hospital readmission.

Competing interests
The authors declare that they have no competing interests.

Authors contributions
All authors participated in the design of the project and the survey tool and carried out the study. CHKY performed the statistical analysis. The first draft of this article was composed

by CHKY and ELYW and was revised critically by all authors. All authors read and approved the final version of the manuscript.

We would like to thank Hospital Authority to provide the logistic and financial support to the study. Also, thank for all participants who took part in the consensus discussion for providing us valuable information.

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JAMA 2004, 291:1358-1367. PubMed Abstract | Publisher Full Text 8. Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, Schwartz JS: Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA 1999, 281:613-620. PubMed Abstract | Publisher Full Text 9. Hyde CJ, Robert IE, Sinclair AJ: The effects of supporting discharge from hospital to home in older people. Age Ageing 2000, 29:271-279. PubMed Abstract | Publisher Full Text 10. Mamon J, Steinwachs DM, Fahey M, Bone LR, Oktay J, Klein L: Impact of hospital discharge planning on meeting patient needs after returning home. Health Serv Res 1992, 27:155-175. PubMed Abstract | PubMed Central Full Text 11. Department of Human Services, Victoria: Effective Discharge Strategy Background Paper: A Framework for Effective Discharge. 1998. Available from:

1. Patient Evaluation

Before any type of aftercare planning begins, a doctor needs to evaluate the patient to determine how much and what type of assistance he will need after his hospital stay. The results of the evaluation should be discussed with the patient or his representative. The doctor also needs to talk to the patient about things such as medications or diet changes following his treatment, what activities he can or cannot do and any medical equipment he may need such as a wheelchair or oxygen tank.

Discharge Planning

The hospital must provide discharge planning if the doctor determines it is necessary for the patient. Often doctors will request discharge planning if the patient needs nursing home care. It is the responsibility of the discharge planner to provide the patient or her representative with a list of possible nursing homes. The planner should also provide the patient with information about the different homes and identify places that have vacancies. While it is the patient's duty to contact the nursing homes and choose the home she prefers, a good discharge planner will continue with a follow-up to the home and provide that agency with medical information about the patient.

Potential Problems

Proper discharge planning can improve the patient's health and reduce readmission to the hospital. However, not all hospitals provide successful discharge planning services, and there is no universal system in the United States for hospitals to follow. According to the Family Caregiver Alliance, 18 percent of Medicare patients discharged from the hospital are readmitted within 30 days. Nowadays, hospitals are releasing patients more quickly, causing improper planning and leading to medical problems down the road. Patients also may run into problems when they are looking for nursing homes. For example, a patient's preferred nursing home may not have any vacancies and the hospital may try to pressure the patient with an alternative choice. If this happens to you, try to be firm with your original choice and see if the hospital can use its influence to get admission into the home. If not, be open to other options, but don't let the hospital force you to live where you would not feel comfortable.

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Provide date of admission and admitting diagnosis. The admitting diagnosis provides information regarding the presenting problem and reason for hospitalization. The diagnosis is a clinical term describing the problem. Avoid lengthy descriptions. Code for the problem, not the symptoms of the problem.

2 Write a summary of the history of the presenting condition. Write a summary of any past treatments provided to the patient for the current complaint by reviewing the patient's records, including the patient's self-reported history.

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3 List test results and findings. State procedures performed, including dates and results.

4 Write a brief summary of the hospital course. Do not include routine tests and procedures, fluid monitoring, blood pressure monitoring and minor medication adjustments. Include treatments pertinent to the diagnosis, along with information regarding any complications. A few sentences are usually sufficient to record the summary of the hospital course.

5 Include final and secondary diagnoses. The final diagnosis refers to the presenting condition and the status of the condition after hospital treatment. The secondary diagnosis refers to ongoing conditions that were not the subject of the current hospitalization.

6 State the disposition. The disposition refers to where the patient is going upon discharge. The disposition may be, for example, the patient's home, the home of another person, a nursing home or rehabilitation facility.

7 Describe the condition of the patient at the time of discharge. Patient should be stable. Include admitting and discharge weight.

8 State recommendations for patient's continued care. Include detailed instructions regarding diet, wound care when applicable, symptoms requiring medical attention, and outpatient appointments. Provide clear and specific details. Anticipate questions the patient or the patient's caregivers may have regarding the patient's care.

9 List discharge medications. Include dosage and instructions regarding frequency and time of day the medication should be taken.

10 Date the discharge summary and provide the name of the person who prepared the report.

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