Creating an agreed discharge: discharge planning for clients with high care needs

Abstract

These findings may be useful for the development of discharge planning guidelines.

Developing an instrument to self‐evaluate the Discharge Planning of Ward Nurses

“…long‐term care or hospitals, or home), search for long‐term care facilities/hospitals on their behalf and coordinate smooth transition in cooperation with a variety of professionals, such as nurses or social workers in the community or in facilities/hospitals (Tomura et al . ). Other countries have discharge specialists, such as nurse practitioners or clinical nurse specialists, who play a similar role (Forster et al .…”

“…The staff assist the identified patient and family decide when they leave the hospital and where they go to (e.g. long-term care or hospitals, or home), search for long-term care facilities/hospitals on their behalf and coordinate smooth transition in cooperation with a variety of professionals, such as nurses or social workers in the community or in facilities/hospitals (Tomura et al 2011). Other countries have discharge specialists, such as nurse practitioners or clinical nurse specialists, who play a similar role (Forster et al 2005, Coleman et al 2006, or a discharge specialist team may be available (Sheppard et al 2010).…”

Transitions in a wicked environment

“…‘The image of life at home held by the client/family is often vague and lacks detail even though they may have strong preferences concerning life after discharge’ (Tomura et al . , p. 448). ‘Irrespective of their age or relationship to the patient, carers [sic] readily identified key aspects of education that they believed could have assisted them in managing their ‘patient’ better, particularly in the first few weeks post‐discharge' (Grimmer et al .…”

Proposing a New Conceptual Model and an Exemplar Measure Using Health Information

“…A number of conceptual models in the literature depict management continuity or the effect of discharge planning and care coordination 21–22 on patient outcomes. Models were also found depicting information continuity in the form of patient handoffs 23 and the use of clinical guidelines, workflows, and pathways.…”