Continuity of care. Patient support from hospital-to-territory care plan: protected hospital discharges

Purpose To facilitate the reception and care of discharged patients, streamlining processes at the University Hospital and promoting a seamless transition to continuity of care services post-discharge. Design/methodology/approach Hospitalised patients undergo the Blaylock risk assessment screening score (BRASS), a screening tool identifying those at risk of complex discharge. Findings Pre-pandemic, patients with a medium-to-high risk of complex discharge were predominantly discharged to their residence or long-term care facilities. During the pandemic, coinciding with an overall reduction in hospitalisation rates, there was a decrease in patients being discharged to their residence. Originality/value The analysis of discharges, with the classification of patients into risk groups, revealed a coherence between the BRASS score and the characteristics of the studied sample. This tool aids physicians in decision-making by identifying the need for a planned discharge in a systematic and organised manner, preventing the loss of crucial information.