Increasing the Efficiency and Effectiveness
of Discharge
g Planning
g Services:
A Tool to Identify Early Those with
Complex Needs and Problems
after
f
Di
Discharge
h
Diane E.
E Holland,
Holland PhD
PhD, RN
AcademyHealth
June 28,
28 2010
Acknowledgements
George J. Knafl, PhD
Professor
University of North Carolina at Chapel Hill
S h l off Nursing
School
N
i
Kathryn H. Bowles, PhD, RN, FAAN
Associate Professor
Biobehavioral Health Sciences Division
New Courtland Center for Transitions and Health
University of Pennsylvania School of Nursing
Funding: NINR T32 #NR009356 (School of Nursing,
University of Pennsylvania) & Dept. of Nursing, Mayo
Cli i
Clinic
Hospital Discharge Planning (DP)
• Essential care process that involves:
• Identification
Id tifi ti off needs
d that
th t will
ill
continue after discharge
• Designing & implementing a plan to
address the needs
• Problems and unmet needs are
i di t
indicators
off DP effectiveness
ff ti
E l Screening
Early
S
i for
f Discharge
Di h
g (ESDP)
(
)
Planning
• Developed
D
l
d to
t identify
id tif early
l in
i the
th hospital
h
it l
stay patients who would benefit from further
DP evaluation
• Unknown if patients with high scores report
more problems
bl
and
d unmet needs
d after
f
discharge than patients with low scores
ESDP
• 4-item screen includes:
• Age
• Walking limitation
• Living alone
• Disability
• High scores (10 or greater) determines those
who should be targeted for focused, inin-depth
DP assessment
• Sensitive and specific (AUC= .82 - .84)
(Holland et al., 2006)
St d Purpose
Study
P
Determine whether patients with high
ESDP
S
scores:
• Report
R
t more problems
bl
and
d unmett
needs after discharge
• Receive more consults to specialized
DP services
• Referred more often for postpost-acute
community services
Methods
• Design: CrossCross-sectional Survey
• Sample/Setting:
• Large
L
Midwest
Mid
t academic
d i medical
di l
center
• Convenience sampling strategy
• Patients who were:
• Hospitalized on one of 2 general medical or 2
•
•
general surgical units
Cognitively intact adults returning home in
community
A stratified
Age
t tifi d by
b national
ti
l estimates
ti t off
categories for hospitalized adults
M th d
Methods
• Procedures:
• Enrolled and ESDP completed within
24 hours of admission
• Survey sent 66-10 days after discharge
• Measure:
• Problems After Discharge
g
Questionnaire (PADQ)
PADQ
Structured questionnaire constructed for research
• Personal care
•
•
(5 items)
Household activities
(7 items)
Mobility
(5 items)
• Equipment
•
•
•
(1 item)
Instructions
(1 item)
Physical function
(10 items)
Psychosocial function
(7 it
items))
Problem: worry,
Problem:
worry limitation,
limitation bother,
bother concern,
concern or
difficulty experienced by patients
Unmet need:
need: A need for help
p identified by
y
patients that is not (adequately) met
(Mistiaen, 1997; Holland, in press)
PADQ Example
Data Analysis
•
•
Regression
Odds ratio estimates
• # problems
– Any at all vs. None
– Average number reported
• # unmet needs
– Any
A att all
ll vs. None
N
– Average number reported
• # consults to DP services
• # referrals for post
post--hospital services
Sample Characteristics
Gender
Male
N(%)
Female
Age
Mean(
Mean(±
±SD)
P
value
Non--responders
Non
Responders
16 (40.0%)
92 (47.1%)
24 (60.0%)
103 (52.8%)
49.6 ((±
±22.5)
55.7 ((±
±20.1)
0.0904
0.4066
Ethnic
White
37 (92.5%)
187 (95.9%)
0.1848
Lived alone
Yes
9 (23.0%)
36 (18.4%)
0.5044
ESDP score
M
Mean
((±
±SD)
6.4
6 4 ((±
±4.8)
4 8)
6 76 ((±
6.76
±4.8)
4 8)
0.6836
0 6836
LOS
Mean ((±
±SD)
6.3 (±
(±7.6)
4.9 (±
(±5.6)
0.2029
Medical
24 (21.8%)
(21 8%)
86 (78.1%)
(78 1%)
0.0314
0 0314
Surgical
14 (11.3%)
109 (88.6%)
Medical/Surgical
DP Consult
Yes
6 (9
(9.2%)
2%)
19 (9.7%)
(9 7%)
0.9033
0 9033
Referral to services
Yes
3 (4.6%)
15 (7.6%)
0.3974
P bl
Problems
& Unmet
U
tN
Needs
d
Low
Screen
Score
(N=150)
High
Screen
Score
(N=45)
P
At Least 1 Problem
N ((%))
147 (98.0%)
45 (100%)
ns
Number of Problems
Mean(±
(±SD))
Mean(
12.2 (±
(±8.4)
16.3 (±
(±8.7)
0.0054
2.303
1.279
1.279--4.147
At Least 1 Unmet
Need
N (%)
113 (75.9%)
42 (93.3%)
0.0178
4.464
1.295
1.295--15.389
Number of Unmet
Needs
Mean(±
Mean(
±SD)
4.3 (±
(±5.2)
4.9 (±
(±4.4)
ns
Odds
Ratio
Estimate
95%
Confidence
Limits
Low Screen
Score (N=150)
High Screen
Score (N=45)
P
Odds Ratio
Estimate
At Least 1 Unmet Information
Need
N (%)
105 (70.0%)
40 (88.8%)
0.0182
3.34
At Least 1 Personal Care
problem
N (%)
37 (24.6%)
20 (44.4%)
0.0125
2.429
Number of Personal Care
problems
Mean (±
(±SD)
0.49 (±
(±1.0)
1.07 (±
(±1.4)
0.0061
2.553
At Least 1 Household Activities
problem
N (%)
89 (59.3%)
(59 3%)
39 (86.6%)
(86 6%)
0.0015
0 0015
4.427
4 427
Number of Household Activities
problems
Mean (±
(±SD)
2.5 (±
(±2.7)
3.9 (±
(±2.8)
0.0024
2.532
81 (55.8%)
33 (76.7%)
0.0249
2.376
Number of Mobility problems
Mean( ±SD)
1.3 (±
(±1.5)
2.0 (±
(±1.6)
0.0081
2.25
Number of Physical problems
Mean (±
(±SD)
2.8 (±
(±1.8)
3.6 (±
(±2.0)
0.0171
2.054
At Least 1 Mobility problem
N (%)
Consults and Referrals
Low Screen
Score
(N=150)
High
Screen
Score
((N=45))
P
value
Odds
ratio
Estimate
DP Consult
8 (5.33%)
11 (24.44%)
0.005
5.863
Referred to postpost-acute
community services
8 (5.33%)
7 (15.56%)
0.026
3.418
Di
Discussion
i
Use of a researchresearch-based decision
supportt ttooll (ESDP) id
identifies
tifi
early in the hospital stay those
patients with more problems and
unmet needs after discharge
Thank you
Holland.diane@mayo.edu