Assessment of discharge risk has been a constant challenge for discharge planners. Shorter lengths of stay have lead to a variety of approaches that will ensure that patients have an adequate assessment before they leave the setting.

　In addressing the question of risk, it is important to consider both risk factors and risk conditions. Risk factors are elements - often behaviour patterns- which tend to predispose people to poorer health. Risk Conditions are general circumstances, over which people have little or no control, that are known to affect health status. An example of risk conditions would be a deprived neighbourhood where the housing is substandard, there are few recreational facilities, community spirit is weak and there are feelings of danger and insecurity. Risk conditions are usually a result of public policy and are modified through collective action and social reform.

　Flow sheets, referral/history forms and guidelines as diagnostic tools are used in health care facilities, yet they do not ensure that the actual risk is addressed. Our post-partum visit flow sheet is an example of a risk assessment that originally quantified the degree of risk of patient and/or family. This form was modified into a yes/no format with comments that replaced actual risk scores to simplify assessment of risk. If the risk was low, the patient was not followed up and cost savings were achieved with this approach.

　

　A classic example of an inadequate risk assessment in Canada was the cancellation of well baby visits while maintaining home visits for only those with high risk. After two incidences of infant mortality, the government re-instituted home visiting and increased the length of stay in hospital up to 60 hours for new mothers.

　

　Risk factors are elements that predispose people to poorer health. The population health promotion model looks at risk as a a full range of factors and conditions that determine health and the ability to cope with an ill relative, beyond the presenting illness.

　The Population Health Promotion Model moves away from victim blaming and calls for action on the full range of factors and conditions that determine health.

　

　This model provides an analytical tool to help develop a clearer picture of those likely to be most at risk. People who, by virtue of their economic and social situation, are isolated and without access to resources and opportunities to participate in their communities experience greater risk. People with few life skills and, who consequently, feel little sense of control over their lives and their environment have greater risk. People who, for a variety of reasons, engage in negative lifestyles and people who do not have access to appropriate primary care and preventive health services are at greater risk.

　Population Health Promotion Model offers a tool for planning health care for both individuals and for communities.

　Health determinants such as income and social status, social support networks, education, employment, physical environment, coping skills, and the availability of health services all must be taken into account when assessing the degree of risk when planning discharge.

　

　The ideas emanating from the various sources have been formulated in a document Strategies for Population Health: Investing in the Health of Canadians which was approved by the Canadian Federal/Provincial/Territorial Ministers of Health in 1994. This document presented the following framework for population health.

　

This document Strategies for Population Health identifies health determinants as:

　

　To incorporate these health determinants into the discharge planning, the nurse has to follow a process to ensure that all determining factors are considered. A complete nursing admission history has to be done in order to screen for patients at high-risk for discharge problems. Reviewing of pre-hospitalization place of residence; family/significant other availability; and community resources used before admission have to be identified.

　The nurse needs to continuously evaluate the patient's response to physical and psychological changes related to the illness/hospitalization. Evaluation of the patient/family's perception of existing health needs and anticipated interventions.

　The nurse has to identify the needs of the client outside of their capabilities and have to refer appropriately. Some examples of health services that a patient may need are:

And finally, to prevent the possibility of readmission, the patient/family needs to be assessed for their understanding of the discharge instructions.

By doing a comprehensive assessment we can consider the extent and type of support a family will need.

Some examples include:

Socio-environmental

Behavioral

Biomedical

　Studies and reports show that the highest risk population include those people of advanced age, multiple and acute chronic illness, including congestive heart failure, chronic obstructive pulmonary disease and coronary artery disease.

　Naylor (1999) demonstrated that with the population of elderly as risk for readmission, good discharge planning and home follow up by an advance practice gerontological nurse reduced hospital re-admissions, increased the length of time between discharge and readmission and reduced health care costs.

　You have a copy of one example of assessment form distributed and guidelines. In addition to routine, name, birthdate, medical condition, family history.

　Form assessed issues are less traditional on our forms:

　Determinants of Health are given extra space to ensure assessment of context for the patient, ie: Socio-environment - poverty, education, social support that we talked about a few minutes ago.

Behavioral - smoking, nutrition

Biophysical - eg. family history, co-marked conditions, etc.

　

　In conclusion, I hope you have seen that we believe the context for our patients is as important as the presenting condition.