Community nurses & discharge planning

Abstract

The role of community nurses in discharge planning for elderly patients leaving hospital is of increasing importance in the wake of the NHS and Community Care Act 1990. Community nurses can play a key role in contributing to pre-discharge assessments and in providing continuing post-discharge assessment and care. The Nursing Research Unit at the University of Edinburgh conducted a survey early in 1993, just prior to implementation of the Community Care Act in Scotland, to ascertain the views and experiences of a national 1 in 3 sample of community nurses relating to the discharge of elderly people from acute hospitals. This article presents the results of that survey and offers recommendations regarding the role of community nurses in discharge planning for elderly patients.

A Rural Perspective on Home Care Communication about Elderly Patients after Hospital Discharge

“…Staff members responsible for communicating patient information are often isolated by their employment settings and scope of practice perceptions (Anderson & Helms, 1993b). Patient referral data are often late, incomplete, or absent from referrals (Worth, Tierney, & Lockerbie, 1994). Providers at receiving organizations, such as an HHA, expend time collecting needed supplemental information (Waters, 1987).…”

Integrated Literature Review of Continuity of Care: Part 1, Conceptual Issues

“…Videotaped information was advocated to improve referrals (Brunham et al, 1992). Adequate notice to home care agencies about patients being discharged from acute care facilities promoted continuity (Hixon, Padios, Schmucker, & Shank, 1992;Williams, Greenwell, & Groom, 1992;Worth, Tierney, & Lockerbie, 1994). Communication between professionals and patients or families was described in nine (23.7%) research reports.…”

“…In 20 studies (52.6%) aspects of coordination and networking processes were specified as influential. Such issues included the need for a structured discharge planning model (Allred et al, 1995;Anderson & Helms, 1993aCooke & Alley, 1992;Haddock, 1991, Magilvy et al, 1994Sterling et al, 1994;Williams et al, 1992;Worth et al, 1994), power and role clarity (Feather, 1993), the use of a community health nurse to assist in discharge planning and coordination (Anderson & Helms, 1993a;Kersten & Hackenitz, 1991;McWilliam & Sangster, 1994;Worth et al 1994), case management (Sterling, Noto, & Bowen, 1994), organizational affiliation (Anderson & Helms, 1993b, size and complexity of the system (Allred et al, 1995;Anderson & Helms, 1993bKersten & Hackenitz, 1991), organizational feedback to assist with process improvement (Anderson & Helms, 1995;Hixon et al, 1992), outpatient coordination and nursing influence (While & Crawford, 1992), unsatisfactory home care services following poorly coordinated care (Klop et al, 1991), overemphasis on efficiency resulting in system fragmentation (McWilliam & Sangster, 1994), physician role (Olsen et al, 1993), and coordinating service providers (Magilvy et al, 1994;Salsberry et al, 1993).…”

Improving networks between acute care nurses and an aged care assessment team

“…This is a cause for concern because, if nurses’ assessment of patient's needs is limited, then important information will go unrecognized in the discharge process. Adding to these problems is evidence that early discharge has negative implications for referral processes from ward nurses to community agencies (Worth et al. , 1994).…”