Table 2 Summary of important component of results

No standardized policy/protocol for discharge process

No standardized tool for facilitating the discharge process

Piece-meal approach in individual hospital

Discharge program targeting high risk readmission which is based on clinical judgment and varies across hospitals

Disease-specific discharge program for selected diseases

Barriers to Discharge Planning

System Factor

Lack of guideline or polices for the standardized discharge process/care pathway

Piece-meal program as pilot and issue of inflexibility of program

Pressure on bed availability

Poor medication system in hospital

Poor communication among healthcare disciplines

Issue of manpower shortage and management

Poor regulation of care quality in old age home

Professional Factor

Unclear role of each disciplines

Nurses not empowered to initiate discharge planning

Unclear or incomplete chart documentation

Low awareness on patient's social needs

Patient Factor

Lack of knowledge of medication/treatment

Mis-concept of hospital discharge

Social Factor

Issue of services availability - waiting time, affordability, equipment loan

Issue of un-match needs of patients - transportation, time gap of service availability and hospital discharge

Poor communication/coordination between hospital and community service provision

Suggestion on Importance Components for Effective Discharge Planning

Standard screening tools to identify high risk readmission case with protocol approach and policy-driven

Discharge planning with multidisciplinary approach

Clear role of each multidisciplinary identified in the discharge planning

Designed nurse/physician for discharge planning as contact point

Clinical pharmacist for medication reconsideration

Trained volunteer for identification/facilitation on patient's psychosocial needs

Effective manpower management

Patient education: medication/treatment, concept of discharge process

Coordination between Hospital Authority/hospitals and community service provision

Enhance training/education on patients' psychosocial needs for physicians

Home carer support program to facilitate transition period from hospital discharge to home