Planning for Patient Safety in Day Hospital Transition
The activities of Phase I of the Planning for Patient Safety study, engaged stakeholders from various groups (day hospital teams, day hospital coordination committee members, community based pharmacists, primary care physicians, GPAT clinicians, day hospital clients and family members).
What is the Current Discharge Process?
Stakeholders identified the current discharge process of being one whereby day hospital clinicians plan the discharge from day hospital at the initial visit and subsequent activities are working toward this discharge.
Specific steps of the discharge process included team reviews, with an assessment of patient progress. If a patient has been determined to be ready for discharge (ie, the teams’ goal are met), the team would then set a discharge date and communicate this to the client and the home care coordinator as appropriate. When asked about the specific activities undertaken to prepare for discharge, participants stated that they would engage in a risk of falls assessment with fall prevention education provided as necessary.
Additional activities would include a referral to an Adult Day Program, as well as communication (verbal and written) with all stakeholders, including community pharmacists, home care and other stakeholders. Some participants identified family conferences as being a part of the discharge process, and almost all mentioned a discharge summary that was sent to both home care and the family physicians. Most participants indicated that there was little or no follow up after an individual was discharged from the day hospital.
What are the Risks and Adverse Events for Day Hospital Clients?
Participants identified a wide range of potential risks and that day hospital clients may experience:
Risks associated with Lack of Support
Participants identified increased risk if there was a lack of formal supports such as community based programs, inconsistent or inadequate homecare providers/provision, and not having a family physician.
Risks associated with Isolation
Participant indicated that the day hospital clients may be at increased risk, if they have inadequate social supports and are experiencing social isolation, including transportation issues. A related discussion included issues of caregiver stress and burnout as a result of dependence on the caregivers.
Risks Associated with Medication Issues
Medication issues, mismanagement of medications and (non)compliance were all mentioned as a risk factor for older adults discharged from day hospital.
Risks Associated with Access to Health Services
Participants identified difficulty accessing health services as a risk factor, which prompted discussions regarding client dependence on the day hospital. Phase I participants indicated that this dependence may precipitate relapses and re-referrals to the day hospital.
Some focus group participants stated that patient “motivation” may influence patient compliance with discharge plans and queried the role of day hospital in case management/medical supervision and monitoring as well as chronic illness monitoring post discharge in helping to manage this risk.
Other risk factors mentioned included the frequency of Emergency Room admissions as well as the number of preventable hospital admission as a result of delays in getting care plan established and operational.
Risks Associated with Functional Status
Participants noted that this population has, upon discharge, typically experienced a decline in their functional abilities which will put them at risk of decreased mobility and risk of falls due to frailty.
What are the Current Modes/Processes of Communication between Day Hospital and Community Based Team Members?
Participants had many perspectives on the current processes of communication within the day hospital teams and with “virtual” team members. Discussion items, comments and suggestions included:
- Face to face and verbal communication was preferred but recognized to be impractical in many cases. Suggestions included better use of discharge letters and interim communication between day hospitals and community based team members that were multidisciplinary in nature. It was suggested that all discharge summaries be dictated by the geriatrician, however this was not universally agreed upon citing time management, rotating geriatricians, and the fact that not all patients are seen by the geriatricians when referred to day hospitals.
- Although family physicians may not always be part of (or aware of) the referral of patients to the day hospitals, all participants felt that communication is key to keep physicians in the care loop and to ensure that family physicians respond to request from day hospitals regarding lab results, medication changes etc…
- Clients, family members and informal caregivers would like to be included in the discharge communication, which from clinicians’ perspectives was important to enacting principles of client centredness. One suggestion was to include the client/family in the discharge conference.
- Technological incompatibilities were noted to be one area of difficulty in the area of communication between onsite and virtual team members. With PHIA concerns, email and other electronic communication methods (seen as being more efficient and effective) were not feasible communication mechanisms. Related to this topic were discussions regarding duplication of assessment processes and documents - participants felt that common forms and processes within and between day hospital sites would be beneficial.
What would be the Ideal Discharge Process from Winnipeg Geriatric Day Hospitals?
Phase I participants had many suggestions regarding the “ideal process” of discharge from day hospital. Key components included:
- A standardized process would be beneficial; this process should be based on team consensus and is clearly communicated to the client at the time of admission to the day hospital.
- Create opportunities for collaboration between onsite and offsite team members prior to discharge; suggestions included - having home care attend the day hospital to see exercise programs implements and receive instruction, or ensuring timely access to adult day programs (perhaps a program lined up prior to discharge).
- Have a larger pharmacy component in day hospitals, and having a funding structure that allowed for pharmacists to conduct home visits.
- Involve the client (family members) in discharge planning. Suggestions included having a family meeting upon discharge, providing information in summary form to the client upon discharge, and having some sort of follow up process implemented to address concerns.
- Implement timely and accessible transportation options for older adults in the community.
- Implement a follow up process for clients discharged from day hospital. Elements included:
- A survey of clients post discharge that assesses more that patient satisfaction, with multiple contacts at 3 and 6 months post discharge
- In home exercise programs prescribed with opportunities for follow up
- A mechanism by which discharge clients can access therapists and case managers with questions, concerns etc…
- Better communication mechanisms between onsite and offsite team members - phone contact between day hospitals and community based pharmacists, home care etc.