In a recent discussion paper submission, the Pharmacy Guild of Australia Primary Healthcare Advisory Group stated that keeping elderly people in their own homes as long as possible is a goal key to better health outcomes. It is generally accepted that as a person ages, the number of medicines they take, the number of chronic conditions they live with, and the number of hospital visits they will require, will increase. A concerning statistic is that as many as one in four elderly patients discharged from hospital will experience an adverse health event within thirty days of hospital discharge.
These events may have serious outcomes, which may include a need for care in an emergency department, readmission to hospital, admission to a nursing home, or out of hospital death. Therefore, it can be stated that transitioning from acute care in a hospital to primary care in the community is a hazardous time for patients. The discharge process is widely recognised as being a critical time in a patient’s hospitalisation, and a point at which process improvement can be made which may reduce the likeliness of readmission.
Several factors that may play a role have been identified. Several strategies have been put into place that attempt to improve the likeliness of a successful transition, with mixed results. Within the discharge process, information sharing has been recognised as an area for improvement. Background Patient centred care has become a central tenet of modern interactions between healthcare providers and patients. This concept has transformed the basis of healthcare from an authoritative health authority to that of the empowered individual.
Patient centred care is defined by the Australian Commission on Safety and Quality in Health Care as “health care that is respectful of, and responsive to, the preferences, needs and values of patients and consumers”. Although intended to put the patient first, this change in dynamic has introduced new expectations of patients. Rather than the patient putting complete trust in their doctor and complying with their doctor’s directives, the modern patient is expected, at least to some extent, to adopt an active role and provide input into their care.
This requires the individual patient to possess skills, confidence, and some level of health literacy about their medications and conditions. This may an unreasonable expectation of some and may result in risky behaviours in others. Not every patient welcomes the opportunity to be more involved in their care, and not all patients are able to do so equally. Patients who are more likely to want greater involvement in their own care are generally female and / or younger patients. Some patients prefer to take a passive role in the transfer of information at discharge.
The role of patients who are looking to play a more active role may be limited at the time of hospital discharge due to adverse effects of treatment medications, or anxiety about going home. In addition, elderly patients living in the community often present a unique set of problems. Elderly patients are more likely to be using multiple medications at higher doses for management of multiple chronic conditions, elderly patients are more likely to be living alone, and elderly patients are also more likely to have decreased dexterity and / or cognitive function.
Such factors may place an unfair burden on patients at a vulnerable time as patients lacking an appropriate level of knowledge about their medications or ability to understand and assimilate information and education provided at discharge may be at greater risk of medication misadventure. Healthcare professionals have also reported several factors that limit interactions with patients. Patient factors include physical deterioration in hearing and cognitive ability and socioeconomic factors such as literacy and spoken language.
Health care providers also face challenges in their knowledge, skills and abilities, and from the environment in which they work. Time constraints and high workloads directly impact the time healthcare professionals are able to spend with patients. Carers are considered to play in caring for elderly patients. Results of one study indicated that approximately half of elderly patients wish to have their family members or carers present during discharge planning, but this occurred in less than one in four cases.
Carers can play an important role for an elderly patient at discharge as advocates for the patient and in retaining information provided during the discharge process. Significance Information, education and communication at discharge are recognised as areas where improvements can be made. Best practice for discharge and transfer from the hospital has been established. The evidence-based clinical decision support website UpToDate states that four elements should be performed during the discharge process.
These include discharge planning, medication reconciliation, preparation of a discharge summary and patient instructions. Several factors are recognised as reducing the likeliness of a successful transition from acute care to primary care. These include adverse events, alterations to the patient’s medications which have not been communicated to the patient, and inadequate planning of the patient’s post-discharge care setting. Additionally, absent or delayed patient follow-up, or failure to hand-off pending tests may also decrease the chances of a successful transition. Finally, atients considered high risk due for other reasons may fail to successfully transition back into the community following hospital discharge.
The patient discharge process can be improved. Results of a study conducted at a major metropolitan hospital in Australia in 2013 indicated that a high percentage of patients (81%) were provided with a documented medication reconciliation and discharge information which included information on when and how to take medications, changes to the patient’s medications since admission, details of follow-up with healthcare providers and expected therapeutic benefits.
However, significantly fewer patients were provided with information such as possible sideeffects (33%) and ‘red flags’ or warning signs that if present would necessitate evaluation by a healthcare professional (22%). Other studies have shown that patients are often dissatisfied with the level of information they are provided at discharge. Lack of information, information that is not tailored to the individual, and a lack of clarity around medication, management of the patient’s condition, and rehabilitation goals are reported to cause confusion, anxiety, incorrect use or omission of medications on returning home.
Medication-related errors are a significant problem. In 2013, the Australian Commission on Safety and Quality in Health Care estimated the number of medication-related hospital admissions to be 230,000 annually at a cost of $1. 2 billion. US estimates are that approximately one in five elderly patients discharged from hospital will experience an adverse event in the first thirty days following discharge and that more than half of these readmissions could be prevented through improved discharge planning and medication management.
While not every adverse event a patient experiences will require further intervention, the results of one study shows that 49% of these patients will either require evaluation by a doctor in a clinic, be admitted to the emergency department of a hospital, or will be readmitted to hospital. A recent Cochrane Review indicates that numerous strategies aimed at reducing the risk of medicine related problems among patients in transition from acute to primary care have been trialled.
Among the findings of the review is confirmation that medication reconciliation is an effective strategy with reductions in medicine use related problems, and improvements in adherence and clinical outcomes. However, there is little evidence to suggest that a single intervention in isolation in either the hospital or community care setting will significantly reduce the likeliness of readmission. A multifactorial approach is required. Aims Healthcare professionals’ perceptions of enablers and barriers in the discharge process may lead to improvements in the discharge process.
While aspects of the discharge process have been considered from other angles, the view of the healthcare professionals involved has not seldom previously been considered. Therefore, the primary aim of this study is to seek the view of healthcare professionals regarding the barriers and enablers of improvements to the discharge process. Secondary to this, a literature review will allow these perceptions to be matched to existing sources of evidence to allow recommendations for change to be made.