Discharge planning is become increasingly important as the average time that patients stay in hospital declines. iCAHE has developed a number of tools designed for patients, carers, community service staff, medical practitioners and residential care staff.
- Evaluation: The PREPARED instruments
- Systems and Process Tools
- Educational Resources
- Allied health data systems
The information in this section is specifically designed to facilitate best practice assessment to assist discharge plans, and to encourage discharge processes that reflect the needs of patients and carers as well as the healthcare team.
Available literature suggests that best practice discharge planning recognises patient's needs, bridges the hospital-community interface through collaboration of hospital and community services and ensures appropriate post-discharge support in the community (Discharge planning: Responsive Standards 2007, Hyde, Robert and Sinclair 2000, Parker et al. 2002, Richards and Coast 2003, Shepperd et al. 2004) (fig 1). Discharge planning can involve a range of organisational activities, which are usually instigated in hospital and continue into the community, in order to ensure that appropriate post-discharge supports are in place in a timely and effective manner.
Whilst the focus of iCAHE is on allied health these tools are relevant across a range of disciplines and fields, and are suitable for most hospital discharge facilitations and post-discharge assessments.
There is no simple way of evaluating the impact of discharge plans on the patient's and family's ability to manage, after the patient is discharged from hospital. The longevity of DC plans is not clear, and requires more research, particularly when there may be a hiatus between leaving hospital and receiving post-discharge community services. Consequently, there is no standard timeframe for measurement (within 24 hours of discharge for instance, or a month after discharge?)
Outcome instruments can be employed to assess change, as long as there is a baseline for comparison (perhaps measured pre-hospitalisation, or during hospitalisation). The iCAHE Outcomes Calculator provides many resources which may be useful for evaluators and researchers, particularly quality of life measures, multidimensional measures and functional measures. The impact of discharge plans is also sometimes measured as patient satisfaction with the hospital stay, however satisfaction is often measured as a global construct and may not reflect the specific impact of discharge plans on core aspects of preparing patients to manage a recent health crisis once they have returned to the community.
iCAHE researchers have developed five congruent, interlinked but independent survey instruments which assess the quality of discharge planning from different stakeholders perspectives (medical practitioners, residential care administrators, community service providers, patients and carers). These survey instruments have sound psychometric properties (Grimmer and Moss 2001, Graumlich et al 2008) and are recommended for use by evaluators and researchers to capture the specific elements of best practice discharge planning. These instruments can be readily scored by hand, or simple statistical analysis programs can be written to capture composite information on the specific domains of discharge planning quality represented in some of the questionnaires. These instruments have all been labelled with the acronym PREPARED (Prescriptions, Ready to re-enter community, Education, Placement, Assurance of safety, Realistic expectations , Empowerment, Directed to appropriate services). These elements reflect the core purposes of best-practice discharge planning.
New users of any of the PREPARED instruments are encouraged to contact iCAHE for advice in administration and interpretation.
- PREPARED for Medical Practitioners (PDF 460KB)
- PREPARED for Residential Care Staff (PDF 374KB)
PREPARED for Community Service Providers (PDF 427KB)
PREPARED for Carers (PDF 283KB)
- PREPARED for Patients (PDF 338KB)
PREPARED evaluation - complete after watching the iCAHE discharge planning DVD
iCAHE's Discharge Planning DVD
The iCAHE Discharge Planning DVD can help patients, their carers and family members understand some of the issues they may face when returning home from hospital.
The iCAHE Discharge Planning Pilot DVD, From hospital to home, is designed to be played on internal hospital broadcast systems, and is complemented by a detailed printed iCAHE Patient Discharge Planning Checklist. (PDF - 421KB)
One minute excerpt of the iCAHE Discharge Planning Pilot DVD: From hospital to home.
Order your copy of 'Hospital to home' here (PDF - 331KB). Cost AU$55, including GST + AU$4.95 postage and handling.
If you would like more information on iCAHE Discharge Planning DVDs please email iCAHE@unisa.edu.au.
Beyond Hospital Gates
20 minute video outlining a number of situations faced by elderly patients upon discharge from hospital. (produced on home video- note: low sound quality)
Discharge Planning Projects
Discharge Planning Booklet (PDF 255KB)
Project Report: Independent community living after discharge from hospital
Executive Summaries (PDF 405KB)
Chapters 1-4 (PDF 951KB)
Chapters 5-9 (PDF 2.9MB)
- iCAHE Discharge Planning Flowchart (PDF 192KB)
- iCAHE Algorithm: Discharge Planning for Patients with Asthma (PDF 238KB)
- iCAHE Discharge Planning Checklist for Patient and Carer (PDF 413KB)
- iCAHE Principles of Discharge Planning (PDF 299KB)
- iCAHE Discharge Planning References (PDF 221KB)
- Crossing the Hospital-Community Interface: Community Services Involvement in the Discharge Process. PhD project undertaken by Michelle Guerin.
- AHRQ Care Coordination Measures Atlas - The Agency for Healthcare Research Quality's new Care Coordination Measures Atlas lists existing measures of care coordination, with a focus on ambulatory care, and presents a framework for understanding care coordination measurement. The Atlas is useful for evaluators of projects aimed at improving care coordination and for quality improvement practitioners and researchers studying care coordination. The atlas features iCAHE's PREPARED Instruments.
Click here to view the project report from a very large project conducted in a number of hospitals around Australia to assess ambulatory allied health activity. While it was completed in 1997, its messages are still relevant today, particularly in terms of identifying data items that are important to capture, that assess allied health activities and outcomes. Enquiries about this report can be made to Professor Grimmer.