International Journal of Gerontology 6 (2012) 237e240

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International Journal of Gerontology

journal homepage: www.ijge-online.com

Review Article

Discharge Planningq
Chin-Jung Lin 1, Shih-Jung Cheng 2, 3, Shou-Chuan Shih 3, 4, Cheng-Hsin Chu 3, 4, Jin-Jin Tjung 1 *
1
Department of Family Medicine, Mackay Memorial Hospital, 2 Department of Neurology, Mackay Memorial Hospital, 3 Mackay Medicine, Nursing and Management College,
4
Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan

a r t i c l e i n f o s u m m a r y

Article history: Discharge planning is an interdisciplinary approach to continuity of care and a process that includes
Received 5 March 2012 identication, assessment, goal setting, planning, implementation, coordination, and evaluation. Effec-
Accepted 13 March 2012 tive discharge planning supports the continuity of health care; it is described as the critical link between
Available online 7 June 2012
treatment received in hospital by the patient, and post-discharge care provided in the community. The
structure of discharge planning is classied into: (1) informal (ordinary) discharge planning and (2)
Keywords:
formal (specialized, structured) discharge planning. Many studies showed that discharge planning may
care coordinator,
increase patient satisfaction, and some studies showed reduced hospital length of stay and reduced
case manager,
continuing care,
readmission to hospital, but no evidence that it reduced health-care costs. A structured discharge
discharge planner, planning tailored to the individual patient probably reduces hospital length of stay and readmission rates
discharge planning for older people admitted to hospital with a medical condition, but the impact of discharge planning on
mortality, health outcomes, and cost remains uncertain.
Copyright 2012, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier
Taiwan LLC. All rights reserved.

1. Introduction and is the quality link between hospitals, community-based

A review of the literature indicates that a hospital often
discharges patients with insufcient planning, poor instruction,
inadequate information, lack of coordination among members of
the health-care team, and poor communication between the
hospital and community1. A hospitals professional staff have had
a long-standing commitment to meet the continuing care needs of
hospitalized patients discharged into the community, both to
enhance a smooth transition from hospital to home or other
chronic care unit and to ensure that the patient will function at an
optimal level. Discharge planning was developed, and has always
been viewed as a major way to improve the quality of care and solve
the postdischarge care problems.
2. Denition of discharge planning
Discharge planning is an interdisciplinary approach to continuity
of care; it is a process that includes identication, assessment, goal
setting, planning, implementation, coordination, and evaluation2
q All contributing authors declare no conict of interest.
* Correspondence to: Dr Jin-Jin Tjung, Department of Family Medicine, Mackay
Memorial Hospital, 92, Section 2, Chung-Shan North Road, Taipei 104, Taiwan.
E-mail address: jinjin0921@yahoo.com.tw (J.-J. Tjung).
services, nongovernment organizations, and carers3.
3. Development of discharge planning
Promotion of discharge planning began in the United State in
1960s. In 1983, Joint Commission on Accreditation of Hospital and,
in 1984, American Hospital Association stated that discharge
planning is required and should be provided to all patients
according to the guidelines of Joint Commission on Accreditation of
Health Care Organizations. It is viewed as the main method for
ensuring that patients postdischarge needs will be met to enable
them to function at optimal levels after they return home. In 1983,
Marcia Abramson presents a model for identifying, clarifying, and
analyzing the ethical dilemmas inherent in the discharge planning
process4. In 1988, Dubbler discussed about the aim of discharge
planning to deal with the ethical issues and to avoid coerced
placement of the elderly in long-term care units5.
With the evolution of the structure and processes of discharge
planning programs, in 1994, the critique concludes with an
exploration of ethical issues and challenges arising from increased
emphasis on cost-effective discharge planning. These include
patients rights; provision of sufcient human, social, and nancial
resources; improved hospital-community communications; and
control over hospital-developed but community-implemented
programs6.

1873-9598/$ e see front matter Copyright 2012, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
doi:10.1016/j.ijge.2012.05.001
238
In 1998, discharge planning became an important nursing
intervention and formed part of the foundation of case manage-
ment practice of managed care7.
4. Purpose of discharge planning
Based on the individual needs of the patient, effective discharge
planning supports the continuity of health care between the
health-care setting and the community; it is described as the
critical link between treatment received in hospital by the patient,
and post-discharge care provided in the community3. The purpose
of discharge planning is to ensure continuity of quality care
between the hospital and the community. In addition, the aim of
discharge planning is to reduce hospital length of stay and
unplanned readmission to hospital, as well as to improve the
coordination of services following discharge from hospital8.
5. Process of discharge planning
The process of discharge planning includes the following: (1)
early identication and assessment of patients requiring assistance
with planning for discharge; (2) collaborating with the patient,
family, and health-care team to facilitate planning for discharge; (3)
recommending options for the continuing care of the patient and
referring to accommodations, programs, or services that meet the
patients needs and preferences; (4) liaising with community
agencies and care facilities to promote patient access and to address
gaps in service; and (5) providing support and encouragement to
patients and families during the stages of assessment from the
hospital9.
6. Structure (model) of discharge planning
In 1985, Mckeehan and Coulton classied the structure of
discharge planning into (1) informal discharge planning and (2)
formal discharge planning10. Informal discharge planning indicates
that discharge planning was done by the attending doctor and the
primary nurse without following any discharge planning procedure
and guidelines, without any communication between the hospital
and the community, and without any discharge planning record. In
formal discharge planning, the patient and the family participate in
the discharge planning process, and there are well-organized
discharge planning procedure and guidelines, good communica-
tion between the hospital and the community, and a detailed
discharge planning record.
In 1990, Debraand Leah used different terms for informal and
formal discharge planning: (1) ordinary discharge planning and (2)
specialized discharge planning11. Ordinary (informal or usual)
discharge planning was provided by the attending physician and
nurses of the inpatient unit. In specialized (formal or interdis-
ciplinary) discharge planning, the hospitals discharge planning
staff include a social worker or a registered nurse of the social work
department.
The structure of discharge planning was classied into the
following models: (1) inpatient units nurse model; (2) discharge
planner model; (3) the hospital liaison nurse model; (4) bedside
nurse model; (5) health-care team cooperation model; and (6) care
coordinator (case management) model12e14.
7. Usefulness of discharge planning and outcome measures
In 1994, Marilyn explored three common assumptions for
discharge planning programs: (1) these are cost-effective; (2) these
allow for enhancement of patients and families quality of life; and
C.-J. Lin et al.
(3) these ensure continuity of care between the hospital and the
community6.
Outcome measures usually include the following: (1) length of
stay in hospital; (2) readmission rate to hospital; (3) complication
rate; (4) place of discharge; (5) mortality rate; (6) patient health
status; (7) patient satisfaction; (8) carer satisfaction, both profes-
sional and nonprofessional; (9) psychological health of patient; (10)
psychological health of carers; (11) cost of discharge planning to the
hospital and the community; and (12) use of medication15.
8. Discharge planner
8.1. What is a discharge planner (continuing care coordinator)?
A discharge planner or continuing care coordinator is a person
who functions as a consultant for the discharge planning process
within a health facility providing education and support to hospital
staff in the development and implementation of discharge plans.
Discharge planners are assigned to plan, coordinate, and
monitor the process of discharge and to implement discharge
policy to assure continuity of care. They coordinate with the
patient, family, health-care team, resources, and services to facili-
tate the transition of the patient from hospital to community or to
another care agency in an individualized, time-saving, cost-effec-
tive, and continuous manner16.
8.2. Who will be a discharge planner?
The discharge planner may be one of the following persons: (1)
social workers2,9,11,17; (2) a nurse18, the patients primary nurse19,
the nurse in charge of the unit20, the hospital liaison nurse13,
a super nurse (clinical care coordinators)21, or a registered nurse
located within the social work department11; (3) inpatient units
nurses and attending physicians; (4) a nurse and social work-
er22e24; and (5) the case manager25.
In 1985, Mckeehan suggested that a hospital-based organization
such as an interdisciplinary committee of staff members designated
to plan discharge is needed6.
9. Tools of discharge planning
A number of tools have been developed to predict discharge
planning outcomes. The most frequently cited include the following:
1. The Hospital Admission Risk Prole (HARP) (by Sager et al in
1996), to predict decline in function, was developed using
a sample of persons aged 65 years or older26,27.
2. The Probability of ReAdmission (PRA) (by Boult et al in 1993), to
predict hospital readmission, was developed using a sample of
persons aged 65 years or older26.
3. The Blaylock Risk Assessment Screen (BRASS) (by Blaylock and
Cason in 1992) was developed to identify elderly hospitalized
patients at risk of more frequent admissions and longer lengths
of stays18.
4. The instruments for patient and family preferences are as
follows:
(a) Patient Participation Preferences Assessment (PPPA)28: The 17-
item, self-report PPPA instrument was developed by the
investigators based on the literature review and its successful
use in initial work. It measures three areas of a patients desire
for participation in discharge planning, including (1) partici-
pation/communication, (2) preference, and (3) desire for
information. The maximum score is 85. The PPPA was pilot
tested in previous works and found to have face and content
validity based on expert review, as well as being easy to use.
Discharge Planning
(b) Family Preferences Assessment (FPA)29: This 31-item instru-
ment is a family parallel to the PPPA. It asks the patients
family/caregiver/signicant others about involvement with
and relationship to the patient, heritage, education, home
location, postdischarge living arrangements, and their view of
the patients preferences, need for information, and desire for
posthospital location. The self-report FPA instrument was
developed by the investigators based on the literature.
The PPPA is a useful, reliable, and valid instrument that can be
used in conjunction with the FPA to assist nurses with
comprehensive discharge planning for greater effectiveness.
10. Impact of discharge planning
Researchers have used various outcome indicators to evaluate
how well discharge planning has ensured the quality and conti-
nuity of care between the hospital and the community30. Length of
hospital stay, rate of unplanned readmission, rate of nursing home
placement, and level of patient satisfaction have been identied as
indicators for evaluating the effectiveness of discharge plan-
ning6,16,31,32. Factors that affect the outcome include the charac-
teristics and preparedness of patients and their family caregivers33.
In 1992, Mamon showed that the involvement of a discharge
planning case manager is related to a signicant reduction in
unmet treatment needs, but not to reductions in activity limitation,
other self-sufciency needs, or overall needs. No signicant effects
of interdisciplinary planning were identied. These ndings
suggest that treatment-related benets result when a case manager
has specic responsibility for the discharge planning of elderly
patients returning home after hospitalization34. One reason why
a formal case manager or high interdisciplinary involvement may
not be a signicant factor in assuring that patient activity limitation
or self-sufciency needs are met is likely to be the patients
nancial/insurance status. Services to meet activity limitation
needs or other self-sufciency needs, although considered impor-
tant by professionals involved in discharge planning, are often not
reimbursable (e.g., lack of Medicare coverage for personal care
services or for transportation services). Consequently, patients may
have to rely on informal caregiver, for example, family and friends11.
In 1999, the review of literature by Lee reported that signicant
process-outcome links were found between discharge planning and
a decreased length of stay35. Naylor reported that the study conducted
between August 1992 and March 1996 for people aged 65 years or
older showed that an advanced practice nurse-centered discharge
planning and home care intervention for at-risk hospitalized elders
reduced readmissions, lengthened the time between discharge and
readmission, and decreased the costs of providing health care. Thus,
the intervention demonstrated great potential in promoting positive
outcomes for hospitalized elders at high risk for rehospitalization,
while reducing costs31. However, in the same year, Elizabeth Mclnnes
reported that no signicant differences were found with regard to
length of hospital stay, readmission rates, or time to rst readmission
with general practice input into discharge planning36.
In 2000, Karen reported that carers rated the quality of planning
for discharge much lower than the patient, indicating that their
needs were often not met when discharge was being planned. In
free text responses, carers expressed their dissatisfaction over
communication about how the family would cope once the patient
returned home37.
In 2005, David reported that a multidisciplinary discharge care
plan, which is initiated before separation, improves quality of life,
involvement and satisfaction with discharge care, and
hospitalegeneral practitioner integration38. Alan founded that the
addition of a clinical nurse specialist to a medical team improved
239
patient satisfaction but had no impact on hospital efciency or
patient safety39.
In 2009, Brian reported that a package of discharge services
reduced hospital utilization within 30 days of discharge40. In the same
year, one review article indicates that a structured discharge plan
tailored to the individual patient probably brings about a small
reduction in hospital length of stay and readmission rates, and an
increase in patient satisfaction, but the impact on health outcomes is
uncertain15. The systematic reviews from 2000 to 2009 of randomized,
controlled, or quasiexperimental trials of discharge planning from
hospital to home of patients aged 65 years or older were examined.
Large effects were noted for patient satisfaction, while moderate
effects were evident for patients quality of life and readmission rates17.
11. Three Cochrane Database systemic reviews
In 2000, the rst review showed mixed results, which may
reect the different study populations and the different ways the
intervention was implemented. There is some evidence that
discharge planning may lead to reduced hospital length of stay and,
in some cases, reduced readmission to hospital. There is also some
evidence that discharge planning increased patient satisfaction, but
no evidence that it reduced health-care costs41. However, few
studies conducted a formal economic analysis. The second review
in 2004 showed that the impact of discharge planning on read-
mission rates, hospital length of stay, health outcomes, and cost is
uncertain8. The latest review in 2010 suggested that a structured
discharge plan tailored to the individual patient probably brings
about small reductions in hospital length of stay and readmission
rates for older people admitted to hospital with a medical condi-
tion. The impact of discharge planning on mortality, health
outcomes, and cost remains uncertain42.
12. Discharge planning for specic diseases or specic unit
12.1. Congestive heart failure
A meta-analysis showed that comprehensive discharge plan-
ning plus postdischarge support for older patients with congestive
heart failure reduced readmission rates signicantly and improved
health outcomes such as survival and quality of life without
increasing costs43.
12.2. Orthopedic patients
Results showed that both completion rate of predischarge
instructions and patient satisfaction were improved with discharge
planning44.
12.3. Elderly patients with hip fracture
Overall, standardized rehabilitation and discharge planning did
not affect postoperative function or institutionalization in elderly
patients with hip fracture. In intervention patients with low social
support, function improved and institutionalization was reduced45.
12.4. Elderly patients with hip fracture due to falling
A discharge planning intervention by a nurse can improve
physical outcomes and quality of life in hip fracture patients46.
12.5. Rural hospital
With discharge planning, there were signicant increase in the
proportion of patients with a timely and informative risk screening,
240
referrals to community health service providers, and improved
communication processes between hospital staff and community
health service providers47.
13. Conclusion
The hospital often discharges patients with insufcient planning,
poor instruction, inadequate information, lack of coordination
among members of the health-care team, and poor communication
between the hospital and the community. Discharge planning was
developed and has been viewed as a major way to solve these
problems, to improve the quality of care, and to help patients face up
to postdischarge care problems. Cochrane Database Systemic
Review in 2000 showed some evidence that discharge planning may
lead to reduced hospital length of stay, reduced readmission to
hospital, and increased patient satisfaction, but no evidence that it
reduced health-care costs. In 2004, the review showed that the
impact of discharge planning on readmission rates, hospital length
of stay, health outcomes, and cost is uncertain. The latest review in
2010 suggests that a structured discharge plan tailored to the indi-
vidual patient probably brings about small reductions in hospital
length of stay and readmission rates for older people admitted to
hospital with a medical condition, but the impact of discharge
planning on mortality, health outcomes, and cost remains uncertain.
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