We need to consider:

　It is important that hospitals and communities liaise in order to provide follow-up care and long-term services provided through rehabilitation facilities, home care, chronic care institutions and other health care programs for discharging patients from the hospital to the community. There is a perception that there are not enough homecare services to meet the demand. Hospitals are trying to address the increased need by increasing ambulatory services and strengthening their relationship with home care agencies. Studies have shown that even a modest targeted intervention can prevent or delay costly re-admissions or nursing home placement. Levine (1999) suggests that discharge planning has to be considered a process, not a last minute event. Discharge has to be started at the time of hospital admission in order to adequately assess and plan for successful discharge. In fact, Arthur (2000) has found that pre-discharge planning with clients awaiting coronary bypass surgery has a positive impact on their recovery and reduces the length of hospital stay.

　Effective discharge planning includes the following key attributes: multidisciplinary, agency cooperation, systems approach, good technological capacity, patient and family involvement. Discharge planning, as a multidisciplinary function, necessitates input from multiple care providers, including physicians, social workers, dietitians, therapists, home care providers, and RNs. Membership of teams vary from setting to setting, but in high-performance teams, the RN is pivotal in identifying and evaluating patient and family preparedness. Consequently, communication with the RN by all care providers is integral to making a successful discharge. Effective discharge planning communication- follow-up care information that is timely, accurate, and complete. Containing costs and ensuring optimal patient outcomes depend on the interdisciplinary collaboration. Nursing administrators and other healthcare managers want to ensure that health professionals communicate and collaborate for an effective patient discharge. Manon (1992) demonstrated that the addition of a discharge planning case manager leads to significant reduction in unmet treatment needs.

　When planning for discharge, specific information needs to be considered including: 1. functional status and patient/family preferences. 2. Community resources need to be identified.

3. The patient's degree of risk needs to be properly assessed. Information needs to be given to the caregivers at home regarding patient care. Technological dependence needs to be taught to both the caregiver and patient.

　In Canada we are experiencing very different characteristics of patients in the community than we did in the past. Of course the characteristics of patients in hospital transfers to characteristics in the community.

　A plan for discharge that is developed in hospital - one that is well thought out may not work out in the community because:

　

E.g., Dressing change at 8 a.m. and 8 p.m. may not be possible if the community nurse has to drive distances between patients. Although in this case the community nurse may be able to teach the patient or family members how to do the dressing.

We find that almost all plans are modified when patients get home based on:

　There are issues about transferring information between:

　

　In our hospitals usually the attending physician is a specialist - surgeon, cardiologist, etc. Family physicians become the 'lead' physician when the patient is back in the community. These family physicians say that they do not always know when the patient is discharged and they do not always receive an up to date record of what treatment the patient has received. Recently our local hospitals have instituted a policy that the discharge summary must be faxed to the family physician at the time of discharge.

　When referrals are made, sufficiently detailed information must be available. Also it is important that these 2 partners - the referring physician and the home care agency are prepared to be flexible. As mentioned a few minutes ago, resources of the family or the agency may change. Also the condition of the patients may change (either better or worse) when they return home. The physician and the agency staff(usually the nurse) must be available to each other to revise the plan, in collaboration with the patient. The most frequent complaints that we hear are that a) the physician does not make time to talk with the home care nurse about the patient care and b) the physician does not receive enough feedback from the community nurse about the patient. Within the home, due to staffing schedules, there often are a number of different people who go into the home-nurses, homemakers, therapist, etc. We find that leaving the patient record in the home allows for the best continuity of care.

　The health professional in home care must become a team player - usually not the leader. In the best cases the patient is the team leader and in other cases it is the patient's spouse, daughter or good friend. For many health professionals the change in hierarchical command in the home brings new challenges.

　The "in-home"leader may not have experience in leading . In this instance, the nurse may become a coach for the leader but not become the leader. The role clarification is very important to ensure the care is carried out in a way that suits the patient needs.

　Home visiting is a very intimate activity. The visiting nurse becomes very close to the family and often becomes a resource for resolving other situations beyond the present medical issue. Eg. She may need to refer the family to other agencies to resolve co-existing issues such as child care.

　The home care nurse is a clinician who must use the best available knowledge to plan care with the patient. We will get back to the topic of using the evidence this afternoon.