Effectiveness of nursing discharge planning interventions on health-related outcomes in elderly inpatients discharged home: a systematic review protocol

Review question/objective The aim of this systematic review is to determine the best available evidence of the effectiveness of discharge planning interventions involving at least one nurse on health related outcomes, including, but not limited to, functional limitations, symptom management, unmet needs and/or health related quality of life for elderly inpatients discharged home. Furthermore, the objective of this study is to assess the relative impact of individual components of discharge planning interventions. Background Growing elderly populations pose significant challenges for health care systems around the world. In the United States the proportion of people aged 65 years or older is expected to grow from 12. 3% to 21. 4% between 2000-2050. 1 As aging is associated with increased utilization of health care services, the demographic trends present a growing problem. In 2007, 37% (12. 9 million) of patients discharged from U. S. hospitals were older than 65 years. 2 The convergence of these issues presents major challenges for several reasons. First, over the past decade there has been growing economic pressure on health care systems to contain and/or reduce costs, which has resulted in shorter duration of hospital admissions. Accordingly, the available time for discharge preparation has decreased significantly. 3 Patients tend to be discharged “quicker and sicker”4 and this can result in adverse events during the immediate post-discharge period. Such problems include medication prescribing errors, poor communication between hospital and primary care physicians and/or lack of coordination with community health care services. 5 Studies conducted in the U. S. have shown that inadequate discharge planning of elderly patients is linked with more frequent readmissions. 6 Notably, between 2003-2004, nearly 1 in 5 (19. 6%) Medicare beneficiaries discharged from U. S. hospitals were re-hospitalized within 30 days with resultant costs of unplanned re-hospitalizations in 2004 reaching 17. 4 billion dollars. 6 However, it has been estimated that 12% of reported adverse events after discharge may be preventable or ameliorated with improved monitoring of patients. 7 Therefore, discharge planning is essential to ensure continuity and consistency of care and several studies have pointed to the need for targeted interventions for those patients with the highest risk for readmission. 8, 9 Hospitalization in and of itself represents a risk for acute functional decline. 10, 11 The immobilization imposed on patients (ie intravenous fluids, confinement to the bed, physical restraints, etc. ) leads to rapid deconditioning and consequently to functional decline. 12 Some studies have described a so-called “hospitalization-associated disability”13, while others report that illness or injuries leading to hospitalization are clearly associated with loss of functional capacity. 14 Further exacerbating this in elderly patients is polymorbidity (including cognitive impairment), which places them at higher risk for functional decline and morbidity (in particular delirium) during hospitalization and heightened vulnerability to adverse health outcomes. 15 The confluence of an aging demographic, decreasing length of hospital stay and inadequate discharge planning creates an environment that demands innovative and effective planning to maintain and improve the health status of elderly patients as they transition from inpatient to ambulatory settings. Several models of discharge planning have been developed to address these challenges. Two models are particularly relevant because they focus on the patient and his or her caregiver. Coleman's “Care Transitions Program”16, emphasizes the role of a transition coach in managing/facilitating the discharge of a patient to home or to a rehabilitation center. This model is based on four pillars: i) medication self-management; ii) patient-centered record; iii) follow-up; and iv) indicators of worsening medical condition with each pillar having different interventions depending on the stage of the hospitalization. Another patient-centered model is Naylor's “Transitional Care Model”17 that outlines comprehensive discharge planning and follow-up for chronically ill, high-risk, older patients. There are several key components to this approach including: 1) in-hospital assessment and development of the discharge care plan by a Transitional Care Nurse/advanced practice nurse/gerontologist nurse; 2) discharge preparation by a multidisciplinary care team; 3) patient participation, this includes communication between nursing staff and the patient regarding the process, and decision-making and patient involvement in discharge planning and discharge education; 4) continuity of care and communication between health care providers; 5) pre-discharge assessment; and 6) post-discharge follow-up. There is growing appreciation of the important roles that family and caregivers provide in support of the discharge planning process. Indeed, some have described families as the “first line of defense against problems”, 18 involving caregivers can help improve recovery and reduce the risk of re-hospitalization. 19 Accordingly, it is widely accepted that the patient and caregiver (s) should be involved in discharge planning interventions including needs assessment, 3, 20, 21 education 22 and decision making. Despite a desire by many families to participate in the decisions with the patient and the health care team, 23, 24 there appears to be a continued shortfall in caregiver involvement in the discharge planning process. 25 A number of the elements of Coleman's “Care Transitions Program” and Naylor's “Transitional Care Model” have been examined in studies examining discharge planning nursing interventions over the past 10 years. 18, 26-31 Indeed, Shepperd and colleagues32 conducted a Cochrane Systematic review, evaluating the effectiveness of discharge planning yet their focus was on economic parameters rather than patient-centered outcomes. Despite a body of literature on the discharge planning process and a substantial number of studies examining specific discharge planning approaches, translating evidence into practice remains elusive in terms of improving patients’ health outcomes. 33 Most studies provide little information about the specific components of the interventions examined. The same critique can be levied against the available reviews; authors compare nursing activities as part of the same discharge planning intervention yet the components are different. Therefore, to address this gap in knowledge, we herein propose a systematic review to deconstruct composite discharge planning studies into defined individual interventions in order to create an intervention model gleaned from the existing literature. Such an approach will enable analysis of associations between different interventions within the model. We believe that this will be a novel contribution to knowledge in this domain as a search of the JBI Library of Systematic Reviews, Cochrane Library, PubMed and CINAHL did not identify an existing systematic review on this aspect of discharge planning.