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Social workers have historically been an advocate for vulnerable groups. One such vulnerable group is elderly patients who have been shown to have multiple, chronic health problems. The current fiscal environment favors shortened lengths of stay, potentially leaving these vulnerable patients at risk for adverse outcomes upon discharge, especially for those discharged home as opposed to institutional settings. The purpose of the study was to characterize the biopsychosocial risks for adverse outcomes in the elderly patients discharged home from Guelph General Hospital (Ontario, Canada). The objectives were to (1) estimate the number of elderly people who indicate biopsychosocial risk for adverse outcomes, (2) determine the specific risks and their severity, and (3) estimate the number of readmissions to hospital within three months after discharge. Standardized, self-reported scales were used to measure risks in elderly patients at discharge from acute care medical and surgical units. The sample included 62 patients with a mean age of 79 years. At discharge almost 40% of the patients were considered at risk for adverse outcomes, 11% indicated depression, 45% indicated psychological distress, 13% showed cognitive impairment, and 62.5% (35/56) had at least one nutritional concern. Over the three-month follow-up period, there were 23 readmissions, 8 ED visits (not mutually exclusive), and 7 outpatient visits. The mortality rate over the three-month period was 5% (3/62). Many elderly patients who were discharged from hospital to home experienced several challenges medically, psychologically and some also experienced social adversities. The implication is that these patients may benefit from a more comprehensive discharge plan than is currently practiced that addresses their challenges.
Preyde et al. (Tue,) studied this question.