Hospital discharge planning: A systematic literature review on the support measures that social workers undertake to facilitate older patients' transition from hospital admission back to the community

Abstract

Objectives To systematically review the literature on measures social workers undertake to facilitate discharge planning for older people in a resource‐scarce environment. Methods Systematic search of electronic databases for peer‐reviewed articles published in English between January 1990 and August 2020. Articles on hospital discharge planning facilitated by social workers for older patients returning home from hospital admission were included. The Mixed Method Appraisal Tool (MMAT) was used to assess quality and risk of bias. The systematic literature review protocol has been registered with PROSPERO on 27 August 2021. Results Six studies from Canada and the United States met the eligibility criteria. The most common support measures employed by hospital social workers when discharge planning for older patients were assessment, education, care co‐ordination, liaison and engagement with families and providers, conflict resolution, counselling and postdischarge follow‐up. Barriers to effective discharge planning were medical complexity, lack of communication, time constraints, limited family support, availability of resources and patient safety. These studies were published between 1993 and 2014 and were not within the Australian context. Conclusions There are limited studies on Social Work discharge planning within the Australian context, particularly on how this important service has been impacted by recent aged care reforms. More research on the topic is necessary to fully understand how aged care reforms such as the National Prioritisation System for Home Care Packages have influenced hospital discharge planning and how social workers have adapted their practice to this challenge.

Medical deserts in Spain—Insights from an international project

“…Integrated health and social care models have been promoted for many years now as an effective approach to improve access to care and limit unnecessary care (e.g., the need for hospital readmissions), especially for the older population. [35][36][37] Due to the general characteristics of the Spanish health care system -existence of separate regional health stakeholders, including local authorities seems especially important in the Spanish context. Without strong and continuous political support, any policy aimed at mitigating medical deserts can face planning and implementation obstacles.…”

“…Strengthening strategic multi‐sectoral partnerships, especially in the face of an ageing population and changing health needs, is important. Integrated health and social care models have been promoted for many years now as an effective approach to improve access to care and limit unnecessary care (e.g., the need for hospital readmissions), especially for the older population 35–37 …”

Healthcare professionals’ perception of barriers and facilitators for care coordination of older adults with complex care needs being discharged from hospital: A qualitative comparative study of two Nordic capitals

“…Related to intended communication ways, we found that participants in both Copenhagen and Stockholm considered the shared electronic communication systems as a facilitator for good coordination of the transition from hospital to home. Previous research has also demonstrated that clear communication between the involved care teams is essential to secure a smooth transition from the hospital to the home [4][5][6][7]. Lack of information in the discharge report sometimes interfered with the planning process in Copenhagen.…”

“…Lack of information in the discharge report sometimes interfered with the planning process in Copenhagen. From previous research we have seen that poor discharge planning from the hospitals tends to cause delays in communication between hospital-based healthcare professionals and health and social care providers in the community, negatively affecting the management of the patients [7][8][9]34]. From previous Danish studies it has been shown that especially homecare nurses difficulties accessing relevant information complicates a safe transition from hospital to home for the patients [11,12].…”

“…Linking planning and management of the activities involved has the potential to generate a coherent scheme of management, which can positively influence management continuity if conducted well [3]. Previous research has demonstrated that clear communication between the involved care teams is essential [4][5][6][7]. The discharge planning should further start as soon as the older person has been admitted to hospital so that necessary services can be identified [4].…”