Enabling legislation, screening/triage, case management, and patient education facilitate more rapid discharge from acute care hospitals. The purpose of this study was to identify factors enhancing and limiting the performance of health care organizations, when it comes to timely discharge. An examination of six high performing organizations in England revealed that the organizational capacity, external environment, and interagency efficiencies influence effective discharge processes.

Background: This study aimed to investigate the nature of discharge planning, and the range and organization of services at high performing sites with lower rates of delayed discharge in English hospitals. In 2003, the British government passed the Community Care Delayed Discharge Act to improve the effectiveness of acute hospital care discharge planning activities. A number of interventions were introduced to grapple with the issue of delayed discharge. For example, a reimbursement scheme was introduced to identify the agency causing the delay and those requiring reimbursement for extra days spent at the hospital. A range of less radical activities included 7-day a week discharges, nurse-led discharges, and protocols informing and educating patients of their rights and responsibilities related to their treatment and discharge.

Methods: Six case studies were developed and a cross-sectional analysis was conducted to identify factors common in 3 or more sites with respect to delays in discharges. These high performing sites were identified based on low rates in delayed discharge and emergency readmissions over 4 years (1998-2002). Each site included a hospital, a local authority, and a primary care organization. Forty-two health and social services staff involved in discharge planning were interviewed. Participants included senior management, operational management, and operational staff. The topics covered characteristics of the local area; existing organizational arrangements between and within health and social departments; decision-making regarding eligibility and access to community resources; front-line discharge planning procedures; characteristics of patient population; information technology; implementation and impact of the reimbursement scheme; role of community health professionals; etc. Relevant data were categorized into recurrent themes.

Findings: Four discharge performance-enhancing factors were identified. Enabling legislation: the Delayed Discharge Act required collaboration between health and social services in developing protocols, training staff, and expanding existing or commissioning new services. Screening/triage: prior to admission, medical assessment units provided short-stay beds to patients before their admissions to acute care; meanwhile their health and social care needs were assessed and community-based services were arranged. Transport services and regular communication between multidisciplinary teams further helped minimize the delays. Case management: hospital-based social services teams were responsible for discharge planning. All the participating sites had access to intermediate care and community services, such as residential and nursing home beds, and community equipment services. Patient education: most sites developed patient choice protocols, which informed patients about their choice of a social care provider and their responsibility to move out when acute service needs had been met.

The study also identified two main factors affecting discharge: a shortage of staff and services for patients with mental health problems, and reportedly poor understanding of the Act by nurses. Other factors included late specification of discharge drugs by doctors and difficulties in managing arrangements for cross-boundary service use.

Conclusions: Enabling legislation, screening/triage, case management, and patient education contribute to low rates of delayed discharge. These findings provide valuable information for health care providers or policy makers on ways to lower delayed discharge rates. The applicability of these factors to other sites needs to be assessed. Further research is needed to ensure that the focus on discharge does not come at a cost to the quality and outcomes of health care.

Reference: Baumann M, Evans S, Perkins M, Curtis L, Netten A, Fernandez JL, Huxley P. "Organization and features of hospital, intermediate care and social services in English sites with low rates of delayed discharge." Health and Social Care in Community 2007; 15(4): 296-305.

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