Community services' involvement in the discharge of older adults from hospital into the community

Abstract

Background: Community services are playing an increasing role in supporting older adults who are discharged from hospital with ongoing non-acute care needs. However, there is a paucity of information regarding how community services are involved in the discharge process of older individuals from hospital into the community.

The Experience of Transitional Care for Non-Medically Complex Older Adults and Their Family Caregivers

“…Difficulties with accessing information about health and diagnosis (Christie et al, 2016; Ellins et al, 2012), poor communication between patients and care professionals around medication and symptom management (Doos et al, 2014; McMurray, Johnson, Wallis, Patterson, & Griffiths, 2007), limited involvement in discharge-care preparations (Baillie et al, 2014; Bauer, Fitzgerald, Haesler, & Manfrin, 2009; Foust, Vuckovic, & Henriquez, 2012), and problems with continuity of care post-discharge (Benzar, Hansen, Kneitel, & Fromme, 2011; Brown, Craddock, & Greenyer, 2012; Foust et al, 2012; Fuji, Abbott, & Norris, 2013) are problems associated with transitional care for older adults with medically complex needs. Such problems are linked to lengthy hospital stays (Lim, Doshi, Castasus, & Lim, 2006), increased rates of rehospitalization (Yam et al, 2010), increased hospital costs (Guerin, Grimmer, & Kumar, 2013), and compromise patient satisfaction and safety (Kripalani et al, 2007). …”

Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study

“…Guerin et al reviewed studies of how community services can work with hospitals across the hospital–community interface and identified four models [32]. The ‘Virtual interface model’, most suitable for straightforward discharges, maintained the traditional approach of staff staying in their respective hospital or community environments and communicating through telephone or written communication, and hospital staff planning discharges and referring to community staff [32].…”

“…The ‘Virtual interface model’, most suitable for straightforward discharges, maintained the traditional approach of staff staying in their respective hospital or community environments and communicating through telephone or written communication, and hospital staff planning discharges and referring to community staff [32]. However, practitioners in different settings often operate independently, with little knowledge of other settings [22, 33] and deficits in communication and information transfer at hospital discharge are common [24, 34, 35] with no established process for information exchange between settings being an identified barrier [33].…”

“…However, practitioners in different settings often operate independently, with little knowledge of other settings [22, 33] and deficits in communication and information transfer at hospital discharge are common [24, 34, 35] with no established process for information exchange between settings being an identified barrier [33]. The ‘In-reach Interface Model’, where community services are located in the acute care sector and are involved in discharge earlier, could be more suitable for older adults with complex discharge needs [32]. With the ‘Out-reach interface model’ hospital staff implement aspects of the discharge plans in the community, a model that could be suitable for older adults with specialised needs [32].…”

“…The ‘In-reach Interface Model’, where community services are located in the acute care sector and are involved in discharge earlier, could be more suitable for older adults with complex discharge needs [32]. With the ‘Out-reach interface model’ hospital staff implement aspects of the discharge plans in the community, a model that could be suitable for older adults with specialised needs [32]. Finally, the ‘Independent Interface Model’ involved an independent person, not employed by the hospital or community service, working across the interface to facilitate discharge, a model that may be appropriate for older adults with complex discharge needs [32].…”