From: Framework and components for effective discharge planning system: a delphi methodology
No. | Statement | % of respondents rated 4–5 on a 5-point scale | ||
---|---|---|---|---|
Clarity | Validity | Applicability | ||
Theme 1: Initial screening | ||||
1a | An initial risk screening should be performed within 24 h after admission to identify those patients with high risk of admission and have complex discharge planning, required to provide ongoing care and additional support after leaving hospital. | 96 | 88 | 42 |
1b | HARRPE (Hospital Admissions Risk Reduction Program for the elderly), a screening tool developed by HA, could be used to stratify those elderly aged 60 or above with a higher risk of hospital readmission. | 96 | 67 | 79 |
1f | The following items should be included in the initial assessment for all patients to serve as flags to trigger discharge planning as appropriate: Any change of ADL: ADL Barthel Index before admission, and on admission (declining ADL index) | 83 | 88 | 67 |
Theme 2: Discharge planning process: including ongoing clinical and functional assessment to facilitate the development of care plan and final discharge plan | ||||
2b | Care plan should be performed within 24 h after admission. | 92 | 71 | 29 |
2e | Systems for the accurate and timely communication of assessment and associated care planning information across clinical disciplines and settings should be developed and implemented to enhance care continuity. | 88 | 100 | 71 |
Theme 3: Coordination of discharge: continuing and timely process from hospital stay to discharge | ||||
3c | Case conference should be considered for high risk patients for better communication between team members in the multidisciplinary team and to enable seamless and timely transition from hospital to community. | 88 | 83 | 71 |
3f | Formal mechanisms for information transfer across clinical and social settings e.g. through discharge summary should be adopted rather than solely relying on informal communication between health and social professionals. | 92 | 92 | 67 |
3g | Prompt provision of all community equipment including walking aids, wheelchairs, low vision or hearing aids, safety alarm, urinal, blood pressure machines, glucometers, visual door etc. should be ensured before discharge. | 88 | 83 | 46 |
Theme 4: Implementation of discharge | ||||
4d | A patient copy of discharge summary and/or nursing discharge summary should be given to patients/carers on the date of discharge. | 100 | 83 | 63 |
4h | When transport is to be used, this should be booked at least 24 h, where feasible, in advance of discharge. | 96 | 96 | 67 |
4j | A “Patient Checklist” should be completed by the patient or carers before discharge to ensure that they understand the discharge plan and their needs are addressed. | 100 | 92 | 58 |