Geriatric Nursing 36 (2015) 451e457

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Geriatric Nursing
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Feature Article

Nursing discharge planning for older medical inpatients

in Switzerland: A cross-sectional study
Cedric Mabire, RN, PhD a, *, Christophe Bla, MD b, Diane Morin, RN, PhD c, d,
Celine Goulet, RN, PhD c, e
a
University of Health Sciences (HESAV), Avenue de Beaumont 21, 1011 Lausanne, Switzerland
b
Service of Geriatric Medicine and Geriatric Rehabilitation, Lausanne University Hospital Center (CHUV), Avenue de Bugnon 46, 1011 Lausanne,
Switzerland
c
Institute of Higher Education and Nursing Research, Lausanne University, Biople 2, Route de la Corniche 10, 1010 Lausanne, Switzerland
d
Faculty of Nursing, Universit Laval, Canada
e
Faculty of Nursing, University of Montreal, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Nursing discharge planning for elderly medical inpatients is an essential element of care to ensure
Received 11 January 2015 optimal transition to home and to reduce post-discharge adverse events. The objectives of this cross-
Received in revised form sectional study were to investigate the association between nursing discharge planning components
1 July 2015
in older medical inpatients, patients readiness for hospital discharge and unplanned health care utili-
Accepted 4 July 2015
zation during the following 30 days. Results indicated that no patients beneted from comprehensive
Available online 31 July 2015
discharge planning but most beneted from less than half of the discharge planning components. The
most frequent intervention recorded was coordination, and the least common was patients participation
Keywords:
Discharge planning
in decisions regarding discharge. Patients who received more nursing discharge components felt
Hospitalization signicantly less ready to go home and had signicantly more readmissions during the 30-day follow-up
Readiness for discharge period. This study highlights large gaps in the nursing discharge planning process in older medical in-
Aged patients and identies specic areas where improvements are most needed.
2015 Elsevier Inc. All rights reserved.

Introduction providers interventions and matching them to patients needs.6

In 2011, people aged 65 years or older represented 17.2% of the
Swiss population, but accounted for 43.1% of hospital discharges.1
Similar observations have been reported in other countries.2,3 In
this older population, the simultaneous presence of several dis-
eases and their related functional impairment, together with psy-
chosocial problems, increases the complexity of care.4
Chronically ill older patients commonly experience health
transitions that require the attention of a wide range of health
professionals from various settings.5 Increased nancial pressure
and a shorter length of hospital stay add to the transition challenges
and require improved care coordination during hospitalization and
after discharge. However, the rising fragmentation of health care
services results in increased difculties in coordinating health care
No potential conict of interest relevant to this article was reported.
Financial support: This study was supported by HESAV, and by a research grant from
The Leenaards Foundation, Lausanne, Switzerland.
* Corresponding author. Tel.: 41 (0)21 316 81 14; fax: 41 (0)21 316 80 01.
E-mail address: cedric.mabire@hesav.ch (C. Mabire).
Furthermore, the time available for discharge preparation has
been signicantly reduced.7 Indeed, most hospitalized older people
are discharged home quicker and sicker8 and are less prepared for
the transition.
To address these challenges, enhanced approaches to the
discharge planning process and a focus on transitional care have
become a priority to ensure optimal transition across care settings.
The discharge planning process is deemed essential to improve the
continuity of care and to avoid or reduce the occurrence of adverse
events after hospital discharge.9 Accordingly, the use of a stan-
dardized discharge planning process is now being considered as a
quality indicator in many health systems.10e14
Despite this observation, the discharge planning process still
lacks a systematic and structured approach in most inpatient set-
tings to address the complexity of health and transitional care in
older people.15 Among the numerous studies published, only a few
have included patients and caregivers perspectives,16,17 even
though most researchers recognize the importance of these per-
spectives for a successful hospital discharge.18,19
Comprehensive discharge planning has been dened as a broad
range of time-limited services designed to ensure health care

0197-4572/$ e see front matter 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2015.07.002
452 C. Mabire et al. / Geriatric Nursing 36 (2015) 451e457
continuity, avoid preventable poor outcomes among at-risk pop-
ulations, and promote the safe and timely transfer of patients from
one level of care to another and/or from one type of setting to
another.20 Its purpose is to smooth the transition from hospital to
home, or to prevent or diminish adverse events after hospital
discharge.21 Key components of this planning have been identied
in several literature reviews.21e23 There are a number of identied
discharge planning elements that are necessary for a successful
discharge, including: (1) communication, (2) coordination, (3)
education, (4) patient participation, and (5) collaboration among
health care personnel.24 When considering the process itself, a
complete and safe hospital discharge planning includes: (1)
assessment of the patient, (2) development of an initial discharge
plan, (3) implementation of the plan, and (4) assessment of the
transition back to the community and follow-up after discharge.25
The Transitional Care Model (TCM) is focused on patient needs
and includes seven patient-centered key components of discharge
planning (Table 1).26 Three randomized controlled trials tested this
model and demonstrated its benets in reducing hospital read-
missions and health care costs in cognitively intact, older adults at
high risk of readmission.27e29 The last trial also showed improve-
ment in patients quality of life and satisfaction.
One cannot examine nursing discharge components without
taking into account the readiness of patients for discharge.30 The
concept of readiness for discharge was rst dened as the feeling of
being prepared to face the transition from hospital to home and to
adapt to changes in health status.31 Later on, it was characterized as
a complex multidimensional, multiphase phenomenon that pro-
vides an estimate of a persons ability to leave the hospital.32 The
concept is described in ve areas: (1) physiologic stability, (2) pa-
tient competency, (3) patient-perceived self-efcacy to handle self-
management regimens, (4) availability of social support, and (5)
access to community resources.33 Information deemed necessary
by this patient for a safe discharge provided by health care pro-
fessionals is a strong determinant of a patients readiness for hos-
pital discharge.18 Assessing readiness to return home provides
some insight into a patients perspective and state of mind just
before discharge, and can potentially allow further adjustments in
care to better address this patients needs.34
To date, only four studies have investigated the concept of
readiness to return home and its relationship to nursing discharge
planning and health care utilization. Results indicated that higher
perception of readiness for discharge was associated with reduced
Table 1
Transitional care model.
Key components
1. The presence of transitional care nurses/advanced practice nurses who lead
the discharge planning process.
2. Early comprehensive assessment of the patients goals, preferences, and
needs. Upon the patients hospital admission, the nurse needs to conduct an
assessment of the patients needs for the post-hospital period and to
establish an initial and provisional discharge plan.
3. Patient and caregiver information and counseling about new treatments,
symptom management, and functional impairments. Consulting in-
terventions include information, actions to encourage and empower self-care
and coping, and assisting the patient to make decisions and solve problems.
4. Patient participation, including enhanced communication between the pa-
tient and the nursing staff and direct patient involvement in the discharge
planning process.
5. Continuity of care and communication between health care providers within
and across health care settings. Coordination of care between the hospital
and home must be prearranged between the primary care providers and the
primary physician.
6. Pre-discharge assessment, or evaluation of whether or not the patient is
ready for the return home.
difculties in coping within 3 weeks of hospital discharge,34 fewer
readmissions at 3 weeks post-discharge,17,35 and increased use of
informal and formal support.36
These observations all suggest the potential signicance of
readiness for discharge as an indicator of the quality of hospital
discharge preparation. Most of these studies were performed in a
US health care environment, and so whether similar results will be
observed in a different health care context remains unclear. In
addition, no study specically investigated the relationship
between the comprehensiveness of nursing discharge components
and patients readiness for hospital discharge. Finally, data are
conicting about the relationship between readiness to return
home and subsequent health care use in older medical inpatients.
The present study had several objectives. The rst was to
describe the usual discharge planning process used in older med-
ical inpatients. A second objective was to investigate the relation-
ship between the comprehensiveness of the nursing discharge
planning process and a) the patients readiness for hospital
discharge; b) unplanned health care utilization after discharge.
The hypotheses were that more comprehensive discharge
planning would be associated with higher readiness for discharge
and lower use of unplanned health care services (readmission,
emergency visits, and community care) after discharge.
Methods
Design
A cross-sectional design was used. Data were collected between
November 2011 and October 2012.
Settings
The study was conducted on medical units in four French-
speaking Swiss hospitals. Three hospitals were classied as
regional hospitals (number of beds ranging from 130 to 197), and
one was a 914-bed academic hospital. These four hospitals have
similar discharge procedures that are based on collaboration
between physicians, nurses, physical therapists, and other health
care professionals, as well as the involvement of a liaison nurse.
This nurse is in charge of assessing patients and caregivers needs.
She determines whether home care services are required and, in
this case, coordinates care between hospital and home. Interdisci-
plinary discharge meetings differed in frequency and team
composition across the four hospitals. Three hospitals had two
weekly meetings, while the last hospital had three weekly meet-
ings. One hospital team included bedside nurses and liaison nurse,
two teams included nurse manager, and the last team also included
a physician assistant.
Sample size
Sample size was calculated based on prior research35 using the
Readiness for Hospital Discharge Scale (RHDS) in people aged 75
years and older whose average score was 8.1 (SD 1.4). In addition,
sample size was estimated using a two-level regression random-
ized effect.37 The following assumptions were made: the average
RDHS score ranged one-half a standard deviation (D 0.35) around
an average of 8.1; patients who received little discharge preparation
had an average score of 7.75 and those who received much
discharge preparation had an average score of 8.45; variance was
the same between the two groups (SD 1.4) and inter-service
correlation was the same among the four medical wards
(r 0.05). Sample size was calculated for a one-sided test of average
differences in the groups with little and much discharge
 C. Mabire et al. / Geriatric Nursing 36 (2015) 451e457
preparation with a standard error of a 0.05 and power (1  b) of
0.90 (Student t test). On this basis, a sample of 196 participants was
required. Considering a 20% attrition rate, an initial sample size of
236 participants was sought.17,35
Participants
Participants were medical inpatients aged 65 years and over,
who had been hospitalized for more than 48 h and were supposed
to be discharged home. Patients were excluded if they had an
estimated life expectancy shorter than 6 months, as were those
with diagnosed cognitive impairment/dementia, as indicated in the
medical records.
This study received approval from the Cantonal ethics com-
mission on human research (CER 307-11). Patients received verbal
and written information about the study and gave their written
consent to participate and be contacted by telephone 30 days after
discharge. They were informed that they could withdraw at any
time. Data were treated condentially.
Data sources and procedures
Study participants were enrolled within 48 h of admission to the
hospital units. During the enrollment period, cognitive impairment
was assessed if not already available in the medical record. On the
last day of hospitalization, readiness for hospital discharge and
anxiety level were assessed. Discharge information was collected
from the medical records after the patients discharge. At 30-day
post-discharge, participants were called to collect information on
unplanned health care services utilization related to their original
admission. If the participants could not be reached, they were
called a second time within a few days; if they were unable to
answer, the caregiver was interviewed.
Measures
Patient characteristics
Sociodemographic (age, sex, etc.) and health-related data,
including patient diagnosis at admission and impact of comorbid-
ity, as measured by the Cumulative Index Rating Scale for Geriat-
rics,38,39 were collected from patients medical records. Clinical
observations showed that patients with cognitive impairment did
not always have a diagnosis noted in their medical record. There-
fore, cognitive impairment was assessed during the rst two days
of hospitalization by the research assistant, using the Mini-Cog.40
Nursing discharge planning
Information about components of nursing discharge planning
was collected from nursing notes, using a structured instrument
based on Naylors TCM components.41 Seven components were
assessed: advanced practice nurse or specialist nurse, early
comprehensive assessment, information and education, participa-
tion, coordination, pre-discharge assessment, and follow-up. For
each component, information was collected on the type (e.g., level
of participation), frequency (e.g., number of educational in-
terventions during hospitalization), and timing of intervention
delivery (e.g., early assessment within 48 h of admission), as well as
on the type of health professional in charge (e.g., nurse, liaison
nurse). For each patients discharge, a grade from 0 (no component
implemented) to 100 (all components completed) was used. This
questionnaire was piloted by three clinical nurses and pretested in
a pilot sample of patients (n 10).
453
Readiness for hospital discharge
Readiness for hospital discharge was assessed using the RHDS, a
22-item scale. Each item was rated from 0 to 10 on a Likert scale,
then the total score averaged by the number of item; higher scores
indicated greater readiness for discharge.34 This self-administered
scale assesses four dimensions identied by conrmatory factor
analysis: (1) personal status described the patients physical and
emotional status immediately prior to discharge; (2) knowledge was
the perceived adequacy of information needed to respond to
common concerns and problems in the post-hospitalization period;
(3) coping ability referred to the patients perceived ability to self-
manage personal and health care needs after discharge; and (4)
expected support was dened as the emotional and instrumental
assistance expected to be available following hospital discharge.34
Although the RHDS has been used only in a limited number of
studies, its psychometric properties appear to be good (Cronbachs
alpha ranged from 0.86 to 0.91). Furthermore, RHDS showed good
predictive ability for post-discharge health care utilization35,36 and
can be used in various population.34 For the present study, the
RHDS was translated and culturally adapted into Swiss French,
using recommendations from Willis et al, who suggested a formal
process called TRAPD: Translate, Review, Adjudicate, Pretest, and
Document.42 Internal consistency of the Swiss-French version was
judged acceptable (Cronbachs alpha 0.76) on the basis of sample
size and number of items.43
Anxiety
Anxiety on the day of discharge was assessed by using the
Hospital Anxiety and Depression Scale (HADS).44 HADS is a 14-item
self-assessment scale used to detect possible (>8) and probable
(>11) depression and anxiety disorders. The HADS is composed of
two subscales of seven item each, the HADS-A and HADS-D, that
assesses anxiety and depression, respectively.
Unplanned health care services utilization
Any use of ambulatory (i.e., general practitioner and specialist
consultations, pharmacists, paramedics, home care providers), and
stationary (i.e., emergency room visits, hospital rehospitalization)
care services, as dened in the Swiss Health Survey,45 was recorded
during a phone call by using a semi structured questionnaire. If an
unplanned service was used, a score of 1 was noted; otherwise, the
score was 0.
Statistical analysis
Descriptive analyses were used to analyze patient characteris-
tics, nursing discharge planning components, readiness for hospital
discharge, and unplanned health care utilization. Random-effect
multilevel regression models were developed to test the associa-
tion between nursing discharge planning components and the two
outcomes.46,47 More specically, a linear multilevel model regres-
sion was used to test the relationship between nursing discharge
planning components and the RHDS scores. A logistic multilevel
model was preferred to test the relationship between nursing
discharge planning components with unplanned health care utili-
zation, a dichotomous outcome.47 The statistical signicance level
was set at p  0.05. All statistical analyses were performed by using
Stata statistical software version 13.48
Results
Characteristics of recruited patients (N 235) are described in
Table 2. The number of participants in each hospital was 50, 61, 63,
and 61, the mean aged was 79.7 (SD 7.6) and about half were
female and lived with a family member. Almost half of the subjects
454 C. Mabire et al. / Geriatric Nursing 36 (2015) 451e457

Table 2 Table 3
Participants characteristics. Discharge planning components performed, perceived readiness for discharge, un-
planned health services utilization (n 235).
Variable Patient sample (n 235)
Participants Mean (SD) or number (%) Variable
Age 79.7 (7.6) Discharge planning componentsa N %
Mini-Cog scorea 4.0 (1.3) Advanced practice nurse/specialist nurse 0.0 0.0
Female 108 (46%) Early comprehensive assessment 120.0 51.2
Caregiver available 110 (47%) Information and education 50.0 21.1
Home cohabitation 124 (53%) Participation 38.0 16.1
CIRS-Gb severec 195 (83%) Coordination 129.0 55.0
CIRS-G extremely severed 101 (43%) Pre-discharge assessment 66.0 28.0
Anxiety (HADSe) 4.7 (3.0) Follow-up 0.0 0.0
Hospitalization in the past 6 months 56 (24%) RHDSb Mean (SD)
Hospital length of stay 9.4 (7.4) Subscales scores
Emergency admission 232.0 (99%) Personal status 8.3 (1.2)
a Knowledge 9.1 (1.1)
Mini-Cog, score ranging from 0 to 5, higher scores indicating absence of
Coping ability 9.6 (0.9)
cognitive impairment.
b Expected support 3.9 (1.7)
Cumulative Illness Rating Scale e Geriatrics.
c Total 8.0 (0.6)
Severe constant signicant disability or uncontrollable chronic problems.
d Unplanned health services utilization during N %
Extremely severe immediate treatment required or end organ failure or se-
30 days after discharge
vere impairment in function.
e Re-hospitalization 29.0 12.4
Hospital Anxiety and Depression Scale.
Ambulatory care 15.0 6.3
Total 44.0 18.7
a
(48.3%) were former workers or industry employees, and 34.8% Percentage of completed components discharge planning.
b
RHDS: Readiness for Hospital Discharge Scale.
worked in a midlevel profession. Almost all enrolled patients
(98.8%) were admitted from emergency departments, mostly for
cardiovascular conditions (33.6%) and infectious diseases (21.3%).
The average length of hospital stay was 9.4 (SD 7.4) days. by physical therapists. Patient participation in decision making
The proportion of nursing discharge planning components regarding their discharge home was rarely documented (16.1%).
performed according to the TCM requirements and reported in While more than half (55.0%) of the components about continuity
nursing documentation was 29.4%, corresponding to less than a of patient care were implemented, those related to pre-discharge
third of expected components. Analysis of the number of compo- were rarely performed (28.0%), and those related to post-
nents per patient indicates that 22 participants (9.4%) did not discharge follow-up were never performed (0%).
receive any components for discharge during their hospital stay Results of the descriptive analyses on the RDHS (Table 3)
(Fig. 1). Three-quarters of participants received one to three com- showed that almost all participants (94.5%) felt ready to go home
ponents: 53 participants (22.6%) had one component, 62 (26.4%) (score 7). Coping ability had a higher mean score, followed by
had two components, and 57 (24.3%) had three components. Only knowledge and personal status (M 8.3, SD 1.2); expected
35 participants (14.9%) received four discharge components and six support score was the lowest (M 3.9). The mean score of the
participants (2.6%) received ve of the seven components required. overall scale was 8.0 (SD 0.6), with a range of 5.3e9.5.
No patient received the full set of seven discharge components. Regarding service use, at the end of the 30-day follow-up period,
None of the nurses in charge of discharge planning was a 44 participants (18.7%) reported unplanned hospital readmissions
transitional care nurse (Table 3), an advanced practice nurse, or a (12.3%), and ambulatory care (6.4%) utilization.
gerontological nurse practitioner (0%). Nonetheless, the needs and To test the relationship between nursing discharge planning
expectations of almost all participants (91.5%) were assessed early components and RHDS score, we performed multilevel regression
on at hospital admission, and in-hospital assessment was one of the analyses (Table 4). Results revealed an inverse relationship between
most commonly performed discharge components (51.2%). Patient discharge planning components and the RHDS scores (B 0.3,
education about functional abilities (21.1%) was mostly performed p < 0.05, 95% CI [0.7, 0.1]). In other words, patients with more

Fig. 1. Numbers of nursing discharge components received by participant.

 C. Mabire et al. / Geriatric Nursing 36 (2015) 451e457 455

Table 4
Results of mixed random-effect regression.

Readiness for hospital dischargea Hospital readmission within 30 Unplanned health services
days after dischargeb utilization within 30 days after
dischargeb

B 95% CI p-value OR 95% CI p-value OR 95% CI p-value

Hospital stay characteristics
Comprehensive discharge planning 0.3 [0.7, 0.1] 0.01 1.1 [1.0, 1.1] 0.05 1.1 [0.9, 1.1] 0.37
Emergency admission 19.6 [35.9, 3.2] 0.02 0.0 [0.0, 0.0] 0.99 0.0 [0.0, 0.0] 0.99
Previous hospitalization 3.3 [1.1, 7.6] 0.14 0.9 [0.4, 2.8] 0.98 0.8 [0.3, 1.9] 0.58
Length of stay 0.1 [0.1, 0.4] 0.28 0.9 [0.9, 1.0] 0.33 0.9 [0.9, 1.0] 0.30
Patient characteristics
Age 0.1 [0.2, 0.3] 0.81 0.9 [0.9, 1.1] 0.94 0.9 [0.9, 1.0] 0.55
Male 1.7 [5.7, 2.3] 0.40 1.9 [0.8, 4.5] 0.16 1.1 [0.5, 2.4] 0.72
Cohabitation 1.5 [6.8, 3.7] 0.56 1.3 [0.4, 4.2] 0.64 1.1 [0.4, 2.9] 0.85
Presence of caregiver 0.1 [4.8, 5.0] 0.97 1.1 [0.4, 3.3] 0.85 1.0 [0.4, 2.5] 0.99
Comorbidities 0.3 [0.1, 0.7] 0.11 1.0 [0.9, 1.1] 0.81 1.1 [0.9, 1.1] 0.51
Cognitive impairment 0.8 [0.4, 2.1] 0.20 1.5 [1.0, 2.3] 0.04 1.3 [0.9, 1.7] 0.09

95% CI 95% condence intervals, OR Odd ratio.

a
Linear regression.
b
Logistic regression.

comprehensive nursing discharge planning reported a lower
perception of being ready for discharge.
To test the relationship between nursing discharge planning
components and unplanned health care utilization, a two-level
random-effect logistic model was used (Table 4). Results did not
show a signicant association between nursing discharge panning
components and unplanned overall health care use (odds ratio
[OR] 1.04, p 0.37, 95% CI [0.98, 1.10]). In contrast, a specic
analysis of the relationship between nursing discharge planning
and 30-day risk of hospital readmission revealed an inverse asso-
ciation of borderline statistical signicance (OR 1.08, p 0.05,
95% CI [1.0, 1.1]).
Discussion
This study provides unique information about the nursing
discharge process in a large sample of vulnerable older inpatients in
the Swiss health care system. In particular, results showed an in-
verse relationship between intensity of nursing discharge planning
components and patients readiness for hospital discharge, an as-
sociation that has never been demonstrated in previous studies.
Thus, contrary to our initial hypothesis, patients who received more
comprehensive nursing discharge planning reported lower feeling
of being ready for discharge. Several explanations can be proposed
for this counterintuitive observation. First, the most likely expla-
nation is that nurses appropriately identied patients who were
less ready for discharge and increased the number of interventions
provided. In this regard, an important additional contribution of the
present study is to question the appropriateness of these in-
terventions to meet patient needs and successfully address patient
perceptions of being unprepared for discharge. In support of this
hypothesis, results of the present study showed that discharge
planning components most frequently targeted the health care
organization rather than the patients themselves. For instance,
interventions to improve interprofessional coordination between
hospital staff and home care providers and ensure continuity of
care were much more frequently provided than patient-centered
interventions, such as education or participation in decision mak-
ing. Indeed, these latter interventions are more likely to affect pa-
tients readiness for discharge, as shown in previous studies.17,49 An
additional explanation could be that a higher number of nursing
components directly contributed to an increased level of anxiety in
these patients, further decreasing their feeling of being ready for
discharge. This was not the case in our study, as the level of anxiety
was not signicantly correlated with the number of nursing
discharge components.
The lack of discharge planning structures and lack of process for
interventions could be another explanation. We were unable in the
present study to collect specic information on the chronology of
the discharge planning process. In future research, it will be
important to know at what point patients receive nursing in-
terventions during their hospital stay. This will determine whether
the preparation for discharge begins early and runs throughout the
hospital stay, or if interventions are provided in the last days before
discharge.
Alternatively, this nding could also suggest that patients
receiving more discharge interventions might be more informed
and therefore more sensitive to their symptoms and more likely to
proactively anticipate their decline in health. However, this
hypothesis is not supported by the observation that, among docu-
mented discharge interventions, patient-centered advice and in-
formation was seldom provided. Information concerning medical
prescriptions, symptoms to watch for, or who to contact if com-
plications occur are essential to prevent rehospitalization.
Several conclusions can be drawn from this study regarding the
discharge planning process. More than half of the participants
received two or fewer components of the seven nursing discharge
components (best practice), and only one in ve participants
received four or more. These ndings clearly suggest that discharge
planning is not yet an established and mature process in current
clinical practice. On the basis of the conceptual framework under-
lying this study (TCM), improvements are mostly needed in patient
needs assessment. Hospitalization is considered to be a transition
process, and nurses not only must meet patients immediate needs
during their hospital stay, but they also must consider the living
context before and after hospitalization.49,50 Most participants had
an early needs assessment, but subsequent components seldom
addressed these aspects. Indeed, patients received few nursing
interventions about education, symptom management, and self-
care, and they seldom participated in decision making regarding
their discharge. Current practice, as seen through nursing notes,
suggests that electronic medical records will offer a welcome
support to integrate all information collected by the various pro-
fessionals to develop comprehensive and structured discharge
planning.
Specic domains for improvement can be highlighted from the
ndings. More specically, all patients do not need comprehensive
discharge planning, for instance, older patients experiencing
456 C. Mabire et al. / Geriatric Nursing 36 (2015) 451e457
multiple hospitalizations. Thus, it is necessary upon admission to
screen patients at risk for complex planning and for complications
or readmissions.51 Successful hospital discharge of frail patients
should be part of a multidisciplinary and coordinated process
involving all health professionals.52 An additional important and
alarming observation from the current study is that, among the
discharge components, active participation and interactive
communication between inpatients and professionals is especially
rare. Putting the patient and caregivers at the center of discharge
decision making is an ethical imperative.53 This result corroborates
those of several other studies showing that older people rarely
participate in decisions about their discharge54,55 and therefore
they are not well prepared for their return home.16,56 The evalua-
tion of the readiness of older people for hospital discharge is one
possible way to promote participation in the process of discharge
preparation.54
Study limitations
Data concerning discharge interventions were collected from
nurses written notes in patients medical records. However, writ-
ten information might not be sufcient to reect the reality of
discharge planning interventions given to the patients.57,58 The
undervaluing of this variable might be an explanation for the lack of
relationship validation. Future research should examine the asso-
ciation between each specic component of discharge planning
and patients readiness for hospital discharge. Indeed, the present
study did not investigate whether essential components, such as
education and patients participation had stronger association with
their readiness for hospital discharge. Finally, it is possible that
patients characteristics such as functional capacity or anxiety in-
uence the readiness for hospital discharge.
Unplanned health services utilization was self-assessed by
patients during a telephone call 30 days after discharge. Potential
memory problems might contribute to undervaluing the rate of
unplanned use of services. Moreover, the distinction between
planned and unplanned health service utilization was perhaps not
clear for some patients or caregivers. It would be more appropriate
to consult data from the health insurance centers.
Despite exclusion of patients with known cognitive impairment
at enrollment, cognitive status (Mini-Cog) remains the most
powerful confounder. This result conrms those of Naylor et al and
further emphasizes the importance of systematically assessing
cognitive status in older persons admitted to the hospital in order
to identify those at higher risk for readmission.59 Interventions
could then be proposed to prevent rehospitalization. Future
research should investigate discharge planning issues in these
especially vulnerable patients.
Conclusion
This study revealed that discharge planning for older inpatients
is seldom performed as a structured, standardized, and compre-
hensive process. Moreover, results show that discharge compo-
nents were more focused on care coordination and institutional
organization (coordination component was more frequent) than on
patients (participation and education were less frequent). This
likely explains the observed inverse association observed between
the number of components provided and patients perception of
being ready for discharge, as well as their risk of readmission. These
results point to specic areas in which improvement is needed as
the population of older persons grows in hospitals worldwide. This
epidemiologic trend requires strengthened continuity of care.
Discharge planning needs to focus on the patient, resulting in early
and systematic needs assessment and a structured and compre-
hensive discharge planning process.
Information, assessments, interventions, and outcomes are
essential to the implementation and monitoring of comprehensive
successful discharge planning. The integration of the type of
information highlighted in this study cannot be achieved without
accurate documentation throughout the hospital stay. For patient
safety,60 communication,61 and quality of care, nurses must supply
accurate information about the patients condition in the medical
records, along with the care that has been provided. As all of these
components cannot be provided without interdisciplinary team-
work, efforts should be made to identify and value this type of
clinical practice. Therefore, the record must contain enough perti-
nent data to enable each member of the team to provide care in an
integrated manner, so that other clinicians can rely on appropriate
documentation to support their decisions regarding patient care.
The ndings of this study show the lack of familiarity with
transitional care among health care providers, even though written
notes might not have reected all nursing activities implemented
and likely underestimated the interventions performed.57,58 Finally,
discharge planning is a complex process, which should be imple-
mented step by step to facilitate the development of discharge
preparation intervention skills. It is essential to take this into
consideration given the recent systematic reviews that concluded
that there is not enough evidence to guide changes in practice and
in light of our counterintuitive results.7,14,21
Acknowledgment
Joanie Pellet (HESAV), research assistant, for her contribution to
data collection.
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