No abstract

Chronic illness appears to be the best indicator for hospital readmission. The crucial time period for hospital readmission during home care is the first 2-3 weeks following hospital discharge. Intensive study of home care service arrangements utilized by readmitted patients, as well as agency variations, are needed. Study findings concerning patients readmitted from home care point to similarities with rehospitalized patients generally. Findings may assist home care clinicians in targeting high risk patients who could benefit from interventions aimed at minimizing unplanned returns to the hospital.

Communication between health care providing organizations is fundamental to discharge planning and continuity of care, but has been reported to be inadequate. Using a classic communication model, the content of communication between hospitals and home health agencies was examined in 300 closed home care records and compared to referral content desired by practitioners. Discharge planners sent about half of the referral information recommended by the literature. Referrals consisted primarily of background data, some medical data, even less nursing care data, and almost no psychosocial data. No referral form was used by the hospital in over one third of the cases. Discrepancies existed between what client care data practitioners identified as important or desirable and the data they actually received. As responsibility for providing health care is decentralized and shared by multiple organizations, communication between providers will play a greater role in ensuring continuity of care. The findings suggest that adoption of standardized, written referral forms might facilitate clear and complete communication.