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Ready for discharge?

Is this patient ready for discharge? This question must be asked endlessly by care staff, managers, and sometimes the patient themselves. In this blog post, I will argue that it is the wrong question and that, by asking the wrong question without thought, we are failing to provide the best care to our patients. Moreover, we fail to organise a more effective and efficient transfer of care. So, what is the correct question? The right question is, “Is the next place ready to receive the patient?” One can judge readiness on four domains. Is the place able to meet the patient’s medical (disease-related) diagnostic and treatment needs? Can the placement meet the patient’s care needs to preserve their safety and well0being? Third, can the next service meet their rehabilitation needs? Last, and equally important to the other three, will the placement meet the patient’s social needs. When the answer to all four questions is, yes, sufficiently well not to risk safety, well-being, further potential improvement or social isolation, the person can be transferred. It is the place that has to be ready, not the patient.

Analysing the problem.

A hospital admission goes like this within the implicit health service model, which is based on a biomedical model of health. Hospitals admit patients for the diagnosis and treatment of a disease. Modern hospitals run like a production line. Once medical actions are complete, the patient should leave the hospital because the human and other resources are no longer necessary for the patient.

A patient is a person. There is more to a patient than their disease. The person may be left unconscious through secondary damage to the brain or irreversible damage to the brain. They may have other conditions needing diagnosis and treatment that do not require a stay in hospital but do need attention. They may need ongoing disease monitoring or care to remain safe; they may need a house to return to or a care package to look after them. Currently, most hospitals do not manage the myriad of other problems. Hospitals consider that other services are responsible for any residual medical, social and care needs a patient has. (see here)

Therefore, instead of taking responsibility for the whole patient, hospitals state that the patient is “ready for discharge”. They mean, “This patient no longer needs our expensive human and capital resource because we have done what is needed to diagnose and control their disease. He should leave.

An alternative phraseology might be more appropriate, “This patient would receive better and more appropriate care in [another setting].” This approach requires (a) the hospital to identify the next setting their patient needs, (b) to make a referral, (c) to organise funding if needed, and (d) to arrange the transfer once a suitable placement is found and is ready to take the patient. Only then is the patient genuinely ready for discharge.

When one rephrases the problem in this way, it becomes apparent what the real issues are.

The problem is not with discharge. The problem is with a transfer of responsibility for meeting the patient’s needs. This change in requirements arises because the original need for diagnosis and management of the disease has reduced sufficiently so that the hospital no longer has an important role. Other conditions have a higher priority, and the hospital cannot satisfy them. This transfer might be to another service within the same healthcare building or the same organisation. Still, it often requires moving to a different service in another organisation in a different location.

At the same time, the problem is not with the patient. All patients will eventually transfer out of the hospital. In the following setting, the patient may require one or more services to meet their needs, and the services may come from one or more organisations. The service responsible for a patient should consider and plan for an eventual transfer and, once the patient no longer needs to be within their service, to arrange the transfer. Many patients will need further support after leaving. The service’s responsibilities are to:

  • identify the patient’s needs that need to be satisfied at the time of transfer
  • discover a service or organisation (or a combination of services and organisations) that can meet those needs
  • contact and liaise with the available services to organise a safe tranfer of responsibility
  • undertake a safe transfer

In most cases, the original service will also have a continuing role, for example monitoring the disease and/or the treatments.

Recognising that discharge is a transfer of care makes it evident that other parties are involved and that the problem of delay does not just concern the patient and the service looking after the patient. The difficulties arising in transferring patients out of an acute hospital are a societal concern. They emerge with the context of healthcare and social service systems but extend further into policies concerning housing and financial support and still further to include most social systems. As a whole, represented by politicians, society must take responsibility for the problem. A notorious case of a child who the hospital could not transfer from inappropriate hospital placement (here) illustrated that a discharge process does not occur in a vacuum and involves political choices.

To summarise, the patient is not the cause of a delayed discharge. The delays arise from difficulties in:

  • the process of tranferring care from one place and service to another and/or
  • the provision within society of a sufficient number and variety of services and placements to meet the needs of patient in society.

In other words, the patient is not the problem. The problem is the responsibility of politicians who determine the resources available. A high level of delays in transferring care reflects a failure of politicians to take their commitment to the public seriously.

Consequence of a delayed discharge process

The consequences of delays in the transfer of care spread out like ripples from the patient across the whole health and social care system and on to the family and other patients. A systematic review of papers describing the consequences of delayed discharges concluded that harms arise throughout the healthcare system. (here)

Starting with the patient, the documented consequences of delayed discharge include man adverse health consequences are considerable, such as:

  • reduced levels of independence in activities,
  • increased risk of death both during the delay and over the next year,
  • many specific complications including hospital-acquired infections,
  • depression and anxiety, and
  • a general loss of quality of life.

The service responsible for the patient also suffers. Staff often feel pressured into discharging people sooner than they wish, and they feel blamed for or guilty about the delay. Stress levels may increase, and morale may drop, especially if staff feel that they have to neglect the patient’s needs to achieve a transfer of care. Interprofessional relationships within hospital teams suffer.

The hospital suffers. Often hospitals are penalised for allowing or, more accurately, experiencing delays in transfer to another care provider or home. This punishment of the hospital leads to stress on the relationship between the hospital and other organisations, a relationship that needs to be good to achieve good patient care. In the UK, the connection with Social Workers and social services is often poor secondary to the joint problem of patients waiting in the hospital. Government policies and the contractual obligations imposed by commissioners exacerbate these consequences; the policies and contractual penalties do not help because they blame the hospital when the system is to blame.

Last, the community suffers, especially other patients. Hospitals work to their capacity. The UK has one of the lowest numbers of beds in developed countries and, as has been evident in the last two years, sustained lack of adequate funding has left no capacity to manage any stress on the system. Delayed discharges stress the system, and other patients needing hospital care, both acute and elective, either fail to receive it or only do so after a delay.

To summarise, delaying a person’s discharge, better considered a delayed transfer of care to a different setting and care provider, harms all parties. It is perhaps particularly harmful in the UK, where health care and social care have been systematically under-resourced for the last 12-15 years. There is no room for adaptation and flexibility within the system.

Studies on transfer of care

This section will discuss a few studies investigating the transfer (discharge) process.

A systematic review of qualitative studies examining the experiences of elderly patients who had been discharged home. (here) The goal was to identify their experience of adapting to living back at home after hospital admission. They identified four overarching themes:

  1. The patient experienced an insecure and unsafe transition. The individual items within this theme covered poor communication both between healthcare professionals within the hospital, and between the healthcare team and the patient. Third, important parts of the process which were poorly performed, attributed to a failure or absence of policies covering discharge.
  2. The patient experienced difficulties adapting to a new situation once home. This included many different items around confidence and being prepared for the transfer, items concerned with lack of social contact and a loss of purpose in life, and a general item of a loss of independence and the new need for care.
  3. The patient’s dependence upon informal care. This mainly concerned a realisation that the transfer only succeeded because family and friends gave much vital support across all spheres. Some patients felt guilty about this.
  4. The patient experienced a paternalistic approach from the healthcare team. The main aspects were the attitudes od healthcare staff and a failure of professionals to listen to the patient.

A mixed-methods study in a tertiary care hospital investigated the discharge criteria from the hospital as perceived by doctors, nurses and patients. The wards studied covered different services, including paediatric services.

The focus groups involving healthcare professionals identified a host of criteria which the authors subsumed into four categories, three of which related to the patient and the last concerning organisational matters:

  • Patient-related factors:
    • a return to an acceptable or safe level of normality, physiological and functionally,
    • not having any further tests needed or equipment to be used,
    • not needing active monitoring of any specific condition
  • Organisational:
    • all arrangements needed for discharge, such as prescribing and supplying medication and arranging follow-up appointments.

In contrast to the extensive range of individual items given by professionals when asked, a review of the written criteria used in different services revealed another picture. Five of the top eleven criteria concerned non-medical criteria, which did not depend upon the patient’s clinical state. Most services set out ‘red flags’ standards, indicating that the service should not discharge a patient. Nevertheless, on review of the notes, services released 53 (12%) of 426 patients despite a red flag.

Strangely, the clinicians seemed to pay little attention to ongoing care needs. Maybe this reflects the nature of a tertiary care hospital, or perhaps it reflects a better-resourced care system in the Netherlands, with little difficulty meeting social care needs.

In another study set within the Dutch health and social care system, Verhaegh et al. (2019) (here) studied 23 patients whose initial discharge was unsuccessful. The 23 patients returned to the hospital within 30 days of discharge. Their qualitative investigation explored the initial release. They identified four relevant themes concerning the discharge process within the patients’ reports:

  • Deficiencies in decision-making support, with two sub-themes
    • Not knowing who the decision-maker is
    • Not being involved in making the decision
  • Aspects of patient education about discharge, also with two subthemes
    • Receiving and understanding self-management instructions
    • Importance of monitoring medication changes
  • Unexpected difficlties in coping with the challenges of recovery after discharge
    • Expectations about recovery; realisation that would not necessarily recover
    • Modification of activities and social roles and activities
  • Feelings about being dependent upon others
    • Feeling of being a burden to informal caregivers

Waring et al. (2016) (here) undertook the third detailed qualitative study of the discharge process. They studied the discharge of people admitted after stroke or hip fracture in two different settings, a small district hospital and a large three-hospital NHS organisation. They interviewed a whole range of professionals from various organisations and interviewed patients and family carers. The focus of the study was on risks associated with the discharge process, the suggested immediate causes, and the suggested distal, systemic causes. The study was interested in the reported perceptions and did not investigate any incidents.

The safety risks associated with discharge fell into four groups:

  • Falls were the most concerning risk including falls in hospital, falls while going home, and falls at home
  • Medicines, their provision, instructions, education and use were a second area of concern
  • Infection, both being discharged with active infection and acquiring an infection after discharge was a third area of concern
  • Relapse, which referred to the patient being readmitted to hospital. This harmful outcome was considered to arise from an inadequate provision of care

The people interviewed for this study identified five areas of immediate causation:

  • Inadequate assessment of a person’s readiness for discharge’. This took many forms including
    • doctors not taking sufficient notice of information given by others, family and professionals,
    • doctors only focusing on the primary disease paying limited or no attention to other diseases present, and
    • the discharging team overlooking or ignoring other problems which may have been present at admission but caused risk atthe time of discharge, such as beeing vulnerable, or having cognitive losses.
  • failure to finish diagnostic testing.
  • failure to organise and provide medication appropriately, which had a large number of systemi causes
  • failure to organise and provide appropriate equipment at home, again arising from bureaucracy and a system failure
  • failure to provide adequate and appropriate care and ongoing monitoring after discharge

The interviewees thought that system-level problems caused these failures. The data showed that arranging a discharge is a highly complex process with many different people, organisations, financial systems, professions and agencies involved. Each has its own culture, resources, and rules different from other agencies or services. All parties have inadequate resources, so the whole process is under pressure. The authors identified five general domains, though they overlap:

  • Planning of discharge and care, with no common approach across wards, professions, services or agencies.
  • Organising discharge, with great difficulties in communicating between services, especially across the hospital-community boundary with different funding rules, procedures and systems
  • Scheduling the discharge and scheduling meetings between hospital and community teams.
  • Resources available differ, and there are different rules for accessing resources and different priorities in providing them.
  • Cultural and managerial diffeences, with a major political and management pressure on hospitals to discharge.

Discussion

Most readers will not be surprised by any of the findings from empirical studies. The discharge process is complex and challenging because it involves many people working in different organisations, each with other methods and priorities. Different system parts have different funding mechanisms, different organisational cultures and rarely share information. Only healthcare has good knowledge about the disease. Expert rehabilitation multiprofessional teams that include medical staff with rehabilitation expertise are not usually involved, so further difficulty arises from inaccurate formulation and prognosis and a failure to appreciate what rehabilitation could achieve.

Complex problems require a multidisciplinary team that includes people from all relevant organisations. In practice, hospitals often delegate responsibility to a discharge coordinator whose role is mainly the organisation of a process. The problem arises within an extensive system, and the solution must involve all system parts. We will only solve it with a single team responsible for a patient’s transfer, working across all boundaries. In other words, it is not sufficient for senior managers in each organisation to agree that organisations should collaborate. Success depends upon the team working with a patient working together within a single framework, not working as a series of bridges between different organisations that still have different rules and policies.

These studies also show that the difficulties arising within transferring care are similar in many different situations. Teams responsible for and policies for transfers of care should be generic, with similar principles and procedures. According to such factors as age, type of hospital, and type of conditions, there will be some differences, but the similarities are more significant than the differences.

The overwhelmingly powerful message is that all attempts to resolve this problem by passing all responsibility to one of many parties, usually the acute hospital, are doomed to fail – as is evident from experience over the last 20-30 years. Moreover, any system of incentives or punishments for perceived failures will reduce cooperation and collaboration between the parties involved.

Second, as is evident from news stories, a failure to take a holistic view of the transfer process and the lack of sufficient resources in all parts of the health and social care system will increase acute hospital problems.

The qualitative studies highlight many vital matters. Services and organisations use a variety of incompatible ways to store documents. They use various measures that all assess the same phenomenon, such as the ability to perform self-care activities. Each service and organisation has its own culture, and these are often very different. The models of illness used to analyse and understand the disease and a patient’s problems vary considerably among various services. The priorities of the organisation usually differ from the priorities in other organisations. Funding rules vary significantly.

In summary, each organisation has characteristics that are often not compatible with features of other organisations also involved with the patient. This difference in characteristics arises within large organisations, for example, between a rehabilitation service and an acute admission service within a single hospital and between organisations such as community health services and local Social Services. The real triumph is that the process works in the face of these barriers.

Discharge – the way forward.

Social care needs sufficient resources to meet the reasonable care needs of our population. Without an adequate quantity and variety of social care resources, including care homes, patients cannot leave hospitals at an appropriate time. The undeniable fact seems to have been overlooked by politicians who believe that technology, privatisation, reorganised management and exhortation will resolve the problem. This belief ignores that most patients depend upon state funding, which has been reduced.

Assuming that sufficient resources are made available (an unlikely assumption, I fear), the different parties need to discuss working within a common framework. The best one is the biopsychosocial model of illness, as it encompasses all the differing interests of various parties. Next, they need to agree on a format or template for referrals from any part to any other part. Given the vast range of patients, services, and settings, this will need to be a high-level outline. Third, there needs to be a discussion on the best way to share important information as responsibility transfers from service to service.

As a first step, the rehabilitation services within an area could combine into a single rehabilitation service. This change would demonstrate that holistic services can function. The learning disability services already use a shared model covering health, social care, and vocational activities. It is not an impossible dream.

In conclusion, for many years, a model of integrated health and social care has been sitting in front of us, the elephant no one recognised. I am sure that the model needs improvement, but it shows what can be achieved. It is the so-called Learning Disability service. We need integrated health, disability and social care services for the population.

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