Enhance discharge planning to end the revolving door of hospital care

March 2006

The Issue: Vulnerable populations with ongoing but non-urgent medical needs are nobody’s responsibility but everybody’s problem

Meet Jean Sauvé, a 72-year-old widower with diabetes and high blood pressure who is on several medications. One morning, Mr. Sauvé wakes up with chest pains. Not having a family doctor he can call, he goes to the emergency room. He’s admitted to the hospital, treated successfully, sent home with updated prescriptions, and told to visit a walk-in clinic if he has any more problems.

Since his wife’s death, Mr. Sauvé lives alone, although his daughter, who lives an hour away, checks in on him twice a week. Weakened by his recent hospital stay, Mr. Sauvé cannot keep up with regular housekeeping or meal preparation — even though adequate nutrition is vital to proper management of his diabetes. He also begins to have problems taking his prescriptions properly, missing doses and taking pills at the wrong times. About a month after his hospitalization for chest pains, Mr. Sauvé is re-admitted, this time for serious problems with his kidneys, a complication of diabetes. When he is stabilized, he moves into a seniors’ home, as his health has now deteriorated to the point he cannot care for himself.

In this situation, everyone loses — Mr. Sauvé is in poorer health, and the system has incurred greater costs because of his second hospital visit. But who is responsible for making sure repeat hospitalizations and institutionalization don’t happen to patients like Mr. Sauvé?

Strategy for Change

Mr. Sauvé’s second hospitalization and institutionalization might have been prevented with a co-ordinated discharge plan that included links to appropriate post-acute homecare, such as signing him up for Meals on Wheels, teaching him to manage his medications, and having regular nurse visits to monitor his diabetes. Research shows that this type of homecare is a cost-effective way to avoid or delay institutional care. And enhanced discharge planning, beginning well before the patient is ready to go home and incorporating effective connections to homecare systems, helps delay or prevent readmissions, reduce days spent in hospital, and save money. i, ii

Unfortunately, Canada does not have a national, comprehensive, co-ordinated homecare system. Patients are sent from the systematic environment of the hospital to homecare, a mix of formal and informal care, some paid for by the government and some paid for by patients and their families, almost none of it co-ordinated in a centralized way that looks simultaneously at all the patient’s needs — physical, mental, and social. For vulnerable populations, such as the elderly and those with mental illness, this can be both confusing and dangerous. ii

Even though all provincial governments have introduced some measure of homecare support, they have usually treated it as an “extra” of the health system rather than actively shifting resources and authority to the community sector. This has led to mounting additional costs without the expected benefits that co-ordination could bring. ii

Research Base

There is no standard for discharge planning, but in most hospitals that researchers have studied usual processes simply meant the patients’ doctors sent them home with prescriptions and referrals if necessary but without actually co-ordinating any follow-up. Researchers studied enhanced discharge planning processes in many vulnerable patient populations. Common features of these include linking staff in the hospital and the community, educating patients and their caregivers about their conditions and how to properly manage them at home, and co-ordinating and putting in place regular patient follow-up and homecare services. iii- x

First and foremost, enhanced discharge plans help reduce re-admission rates, both for the original problem that sent the patient to hospital and for all other reasons. By ensuring patients are properly cared for at home, discharge planning can reduce hospital re-admissions. In the study with the longest follow-up period, elderly patients hospitalized for several medical problems were tracked for six months; researchers found that 37 percent of patients receiving usual care were readmitted, while only 20 percent of patients receiving comprehensive discharge planning were. v Other studies looking at patients with congestive heart failure, mental health problems, and stroke, among other problems, found similar reductions. iii, iv, vi- viii

In addition, innovative discharge plans can reduce a patient’s length of stay. Two Canadian studies found significant reductions. First, a study in Newfoundland in the early 1990s found patients in acute care hospitals could be discharged up to one day early if they had access to enhanced discharge planning. ix Second, a study of patients with mental illness in Ontario from the late 1990s and early 2000s found patients being discharged about four months earlier than those in the control group, largely because hospital staff knew appropriate community supports were in place. x

These reductions, both in bed-days and re-admissions, save hospitals (and tax payers) money. The Ontario study’s intervention with patients with mental illnesses saved $12 million over one year, on just 13 hospital wards. x Two American studies that looked at the cost to re-hospitalize patients found the control group had per-patient costs that were $1,058 iv and $3,093 v higher than the intervention groups.

Conclusion

Vulnerable populations, such as elderly heart patients and people with schizophrenia, benefit greatly from enhanced discharge planning that includes co-ordinated links to and provision of homecare. Assuming the necessary community resources are available as part of the continuum of care, these patients can be spared unnecessary hospitalizations and institutionalizations in a very cost-effective way. [Arundel, Chappell]