There are many issues in discharge planning. The community care agencies are often not involved in discharge planning. There are not adequate numbers of health personnel in the community who are educated to take care of complex patients. It is important that health care workers in the community have the following attributes-team player, coach, confidant and counselor and an advanced clinician in the delivery of health care in the community. Another critical issue is the lack of exchange of adequate information in the field, the physician and home care agency.
Communication Systems
Traditionally the transfer of information was verbal from a discharge planner in the hospital to the appropriate community agency. Now, in some countries, the use of technology allows information to be downloaded from a hospital record to community services. Devices such as Palm Pilots are carried by nurses which contains essential patient information and are updated. Large amount of data are stored on CD ROMS which can be transferred between institutions, and make the exchange of information faster and more efficient. As previously mentioned patients and their families are increasingly using the internet as a source of information to answer questions about problems they are encountering at home as they attempt to care for chronically ill patients. At this point the most common form of communication between hospital and agencies is the telephone and fax machine. Traditionally the patient information that is transferred is minimal and not enough to do comprehensive planning. Assessment tools that we will be discussing in a future session are suitable to electronic entry and transfer. The Province of Quebec has set an objective to computerize every home by 2005. This type of network will enhance the possibility of using electronics to maximize its effect in ensuring continuity of patient care. One Japanese study (Kitamura, 1998) recommended the use of a stroke registry to obtain the overall characteristics of stroke patients and be able to use the registry to promote community wide programs and to predict home care needs.
Telemedicine systems (Kee, 1998) have been used by nurses in home health care. There is literature which discusses the effectiveness of telephone reassurance programs as an adjunct to discharge planning. Additional support such as in-home monitoring devices transmits data that uses the telephone to respond to a series of assessment questions.
