Experiences of elderly patients regarding independent community living after discharge from hospital: a longitudinal study.

OBJECTIVE: To describe the reported experiences of elderly patients regarding their transition from an acute hospital to independent community living. DESIGN: Observational longitudinal study based on semi-structured interviews conducted monthly for 6 months following discharge from hospital. SETTING: Four South Australian acute hospitals. Patients. One hundred elderly patients who faced a long-term change in health status and/or in their ability to manage practical aspects of daily living. MAIN OUTCOME MEASURES: Experiences in managing change in health status, social circumstances and independent community living. RESULTS: Few patients believed that discharge plans made in hospital had assisted their return to independent community living. Discharge planning addressed mainly formal health services rather than practical aspects of daily living. Many patients implemented innovative solutions when formal services were unavailable or inadequate. Pain, tiredness, loss of mobility, and grief over loss of previous abilities were frequent, long lasting sequelae to illness, and few discharge plans prepared patients to deal with this. CONCLUSIONS: Elderly patients who have left hospital to face a permanent change in health status often regret that they have not been better prepared for what lies ahead in terms of more specific information about their condition, linked with practical discharge plans that prepare them for their period of convalescence. We suggest that the underlying problem is a disjunction between the multiple systems involved in hospital discharge planning, primary medical care, disability-oriented community health services, and informal community services.     

Functional impact of hospitalization among elderly patients

OBJECTIVE: To describe functional capacity changes of elderly during hospitalization and to assess the correlation of these changes at the time of hospital discharge and sociodemographics and clinical variables. METHODS: There were studied 94 patients aged 65 to 94 years admitted to a geriatric-gerontological hospital unit of a school hospital. The first functional capacity evaluation (number of daily living activities impaired) of the elderly patients was carried out up to 24 hours after admission and the last one immediately after discharge. Routine therapeutic interventions were performed by an interdisciplinary health care team in the study period. Data was analyzed using Chi-square test (alpha< or = 0.05). RESULTS: Of all patient studied, 25.6% improved their functional capacity, 34.0% had not had functional changes, 19.1% had worsened functionally, and 21.3% died during the study period. A significant correlation was seen between functional deterioration and cognitive deficits, delirium, and low functional capacity at admission. CONCLUSIONS: Functional capacity is an important marker of health in hospitalized elderly. Functional improvement during hospitalization is associated to lesser impairment in daily activities at the time of admission and better clinical conditions.     

Hospital care at home: an evaluation of a scheme for orthopaedic patients

We report on an evaluation of the practicality and acceptability of the 'Going Home Service', an early discharge intensive patient support scheme for orthopaedic patients in their own homes. Patient outcomes were assessed in terms of health and functional status and the impact on patient's carers was assessed. Eight-seven patients who were successfully discharged from the service were compared with 17 patients readmitted to hospital prior to their discharge from the service, 44 patients suitable for the service who did not take it up and 15 patients discharged from hospital traditionally immediately prior to the service becoming operational. Data were collected via face to face semistructured interviews and note searching. Twenty-six of the patients' informal carers were also interviewed. The majority of patients in all four groups were elderly women, readmitted patients being significantly older than those successfully discharged. The readmitted patients were also more likely to have been admitted originally for traumatic surgery and less likely to have been independently mobile prior to the initial admission. Hospital length of stay was shorter amongst Going Home Service patients than those cared for traditionally, but the total episode of care was greater. Patients and carers were well satisfied with the service. Although there was no evidence that quality of life or functionality were affected by their early discharge, at three months post operation, there was some evidence that Going Home Service patients were experiencing less pain than those discharged traditionally. This early discharge service provided a good quality of health and social care for the majority of patients. However, it did not suit all patients and a minority were re-admitted. The findings reported here add to those obtained in other settings and highlight new aspects for consideration in the planning and delivery of high quality hospital at home schemes.     

Discharge Planning Quality from the Carer Perspective

Discharge planning endeavours to assist the transition of patients from the acute hospital setting into the community. We examined the quality of discharge planning from the perspective of the carer. Spouses were the most common carers for the elderly patients in our study. Many carers were also elderly, with their own health problems. Using a new instrument (entitled PREPARED) (K. Grimmer and J. Moss, Int J Qual Health Care (in press)), carers rated the quality of planning for discharge much lower than did the patient, indicating that their needs were often not met when discharge was being planned. In free text responses, carers expressed their dissatisfaction over communication about how the family would cope once the patient went home. Carers generally had lower summary mental quality of life scores than the Australian norms (as measured by the SF-36 health survey (J. Ware and R. Sherbourne, Med Care 1992; 30: 473–483)), suggesting that the caring role may have impacted upon their emotional wellbeing. The rate of use of community services in the first week post-discharge was low, suggesting that carers and patients carried the majority of the burden immediately after discharge. We suggest that planning for hospital discharge requires more consideration of the carer. This revised version was published online in July 2006 with corrections to the Cover Date.     

The cost-effectiveness of rehabilitation in the home: a study of Swedish elderly.

OBJECTIVES. To investigate whether care of elderly and disabled patients could be more cost-effective after a short-term hospital stay, we examined the impact of a primary home care intervention program on functional status, use and costs of care after 6 months. METHODS. When clinically ready for discharge from the hospital, chronically ill patients with dependence in one to five functions in personal activities of daily living were randomized to physician-led primary home care with a 24-hour service, and the controls were offered ordinary care. Physical, cognitive, social, and medical functions were assessed in 110 team subjects and 73 controls. Data regarding inpatient days and outpatient visits were collected and converted to costs. RESULTS. Team patients demonstrated better instrumental activities of daily living and outdoor walking and significantly fewer diagnoses and drugs at 6 months. They used less inpatient and more outpatient care compared with the control patients. Significant cost reductions were found in the team group. CONCLUSIONS. This primary home care intervention program is cost-effective, at least for a selection of patients at risk for long-term hospital care.     

The Effectiveness of a Health Promotion Program for the Low-Income Elderly in Taipei,Taiwan

This study assessed the effectiveness of a health promotion program for low-income elderly provided by trained low-income home health aides. Indicators of the effectiveness of this program included improvement in physical health, psychosocial health and functional status, including activities of daily living (ADL) and instrumental activities of daily living (IADL) as well as changes in perceived health promotion needs. This evaluation study used a single group pre- and post-test experiment design. After informed consent forms were signed by participants, 89 purposively selected low-income elderly (aged 64–96) completed pre-test structured surveys, while 60 participants (aged 68–96) completed post-test surveys. Post-test scores indicated improved nutritional status (paired t = 2.64, p < .05) and chore management of IADL abilities (paired t = 2.83, p < .01). No significant difference in psychosocial status were found between pre- and post-test scores. Perceived needs for health promotion services decreased after the intervention. The results show that the health promotion services were effective in improving health status and decreasing perceived needs for services among low-income elderly in Taipei. Recommendations based on this study for developing services for the low-income elderly must take health promotion intervention into consideration.     

Outcomes after stroke: Basic and instrumental activities of daily living, community reintegration and generic health status

This study describes the discharge destination, basic and instrumental activities of daily living (ADL), community reintegration and generic health status of people after stroke, and explored whether sociodemographic and clinical characteristics were associated with these outcomes. Participants were 51 people, with an initial stroke, admitted to an acute hospital and discharged to the community. Admission and discharge data were obtained by chart review. Follow-up status was determined by telephone interview using the Modified Barthel Index, the Assessment of Living Skills and Resources, the Reintegration to Normal Living Index, and the Short-Form Health Survey (SF-36). At follow up, 57% of participants were independent in basic ADL, 84% had a low risk of experiencing instrumental ADL difficulties, most had few concerns with community reintegration, and SF-36 physical functioning and vitality scores were lower than normative values. At follow up, poorer discharge basic ADL status was associated with poorer instrumental ADL and community reintegration status, and older participants had poorer instrumental ADL, community reintegration and physical functioning. Occupational therapists need to consider these outcomes when planning inpatient and post-discharge intervention for people after stroke.     

Home health care and rapid rehospitalization

Early release from the hospital of the elderly ill patient may lead to failure of the home care plan and rapid rehospitalization. Review of 330 consecutive admissions to a large urban home health agency in 1980 revealed that 43 patients (13%) were rehospitalized within 2 weeks of admission. This high risk patient population is contrasted with the average home care population in terms of living arrangements, ambulatory status, primary diagnosis, age, sex, medications, etc. Home care was probably the appropriate long-term placement if better coordination between discharge planners, PSROs, physicians and home care staff could have been established with the extension of the hospital stay by 1-2 days and/or the provision of more intensive supportive care in the home at the time of admission to the home care agency. Simple guidelines for medical/social discharge planning to provide safer transfer of ill elderly patients from hospital to home are listed.     

Is Health-Related Quality of Life an Independent Prognostic Factor for 12-Month Mortality and Nursing Home Placement Among Elderly Patients Hospitalized via the Emergency Department?

ObjectivesTo assess whether health-related quality of life is an independent prognostic factor for mortality or nursing home placement in frail elderly patients.DesignA prospective, multicenter study with a 12-month follow-up.SettingNine French hospitals.ParticipantsA total of 1306 patients aged 75 and older hospitalized through an emergency department.MeasurementsData obtained from sociodemographic characteristics, Comprehensive Geriatric Assessment and the Duke Health Profile (DHP) were used into a Cox model to identify prognostic variables for 12-month mortality and institutionalization.ResultsCrude mortality and nursing home placement rates were 34.1% (n = 445) and 16.1% (n = 210), respectively. Independent prognostic factors identified for mortality were: Comorbidity level (moderate: hazard ratio [HR] [95% confidence interval (CI)] = 1.40 [1.09–1.78]; severe: 2.70 [1.63–4.46]), dependence for activities of daily living (1.68 [1.06–2.67]), pressure sore risk (1.49 [1.16–1.90]), risk of malnutrition (2.09 [1.46–3.00]), delirium (2.25 [1.75–2.90]), and 10-point increase in the DHP perceived health score (0.96 [0.93–0.99]). Independent prognostic factors identified for nursing home placement were the following: living alone at home (1.82 [1.30–2.55]), having 2 children or more (0.71 [0.51–0.99]), dependence for activities of daily living (2.48 [1.39–4.44]), dementia (1.93 [1.39–2.69]), unplanned hospital readmission during follow-up (2.05 [1.45–2.91]), and 10-point increase in the DHP social health score (0.90 [0.83–0.99]). Balance troubles and risk of malnutrition were no more significant when adjusted for the DHP scores and other clinical variables.ConclusionThe perceived health and social health scores of the DHP were independent prognostic factors of survival and nursing home placement among hospitalized elderly patients, respectively. When associated with Comprehensive Geriatric Assessment, they could help screen frail patients to set up as early as possible targeted interventions to restore/maintain modifiable prognostic factors, such as nutritional status, functional ability, and social support.     

Functional transitions among the elderly: patterns, predictors, and related hospital use.

OBJECTIVES. This paper describes 6-year rates and correlates of functional change in the elderly, as well as associated hospital use. METHODS. The Longitudinal Study on Aging (n = 7527) and matched Medicare claims were used to calculate 6-year functional status transition rates and hospital use rates. A hierarchical measure that incorporated activities of daily living, instrumental activities of daily living, and competing risks of institutionalization and death was used to assess functional status. Multinomial logistic regression was used to predict 1990 status. RESULTS. The functional status of 12% of men and women 70 to 79 years of age who were initially impaired in instrumental activities of daily living improved, and about half of the initially independent people in that age group remained so. Multivariate analyses revealed that age, baseline functioning, self-rated health, and comorbidity predicted 1990 status. Both baseline functioning and functional change were related to hospitalization. CONCLUSIONS. This study supports others that have shown some long-term functional improvement, but more commonly decline, in the elderly. Furthermore, it documents the link between functional decline and increased hospital use.     

Posthospital needs of elderly people at home: findings from an eight-month follow-up study.

In a study of 737 elderly hospital patients discharged to their homes in suburban areas northwest of Chicago, Illinois, 60 percent were assessed as needing help with personal care or housekeeping. Only 19 percent were referred by the hospital to community service agencies and, in the immediate postdischarge period, a large proportion of help in both personal care and housekeeping was given by relatives. Eight months after discharge, however, the proportion of care provided by relatives had decreased and the proportion of paid help had increased. The use of help at both points in time was strongly related to limitations in the basic activities of daily living (ADL) at time of hospital discharge. Many patients were unaware of available community services, and 64 percent said that no one in the hospital had talked with them about managing at home. These findings indicate the need for rethinking criteria for hospital discharge planning, more effective communication between service providers and patients, and community focus of attention on elders coming home from the hospital.     

Can a house call by a public health nurse improve the quality of the discharge process for geriatric patients?

OBJECTIVE: To determine whether there was any benefit from a single house call by a health visitor (a public health nurse) to an elderly person after discharge home from a geriatric hospital. METHODS: A randomized controlled trial with blind assessments at 28 days was conducted. Subjects included residents of Bath, England, with an average age of 83 years, who were discharged consecutively from a geriatric hospital to their homes. Intervention was a single visit by a health visitor 72 hours after discharge, to ensure the patient was settled at home, or normal post-discharge care. Outcome measures taken at 28 days by a research nurse included survival, hospital readmissions, nursing home admissions, cognitive and physical function, services requested and supplied, and drug therapy. RESULTS: There were no important differences between the intervention and control groups at 28 days on any of the outcome measurements. The control subjects did better than the study subjects on many of the outcome measures. CONCLUSION: A house call by a health visitor to elderly patients after discharge from geriatric wards does not measurably improve the quality of the discharge.     

Use of health care services after stroke.

OBJECTIVES--To describe the use of care before and after stroke and to evaluate equity in access to health care services after stroke. DESIGN--Cross sectional study. SETTING--The Netherlands. PATIENTS--382 patients living in the community who had been admitted to hospital with a stroke six months before. MAIN MEASURES--Sociodemographic status and functional health status according to The Barthel index, Rankin scale, and sickness impact profile, assessed during interview, and general practitioner (GP) characteristics obtained by postal questionnaire. Univariate and multivariate analyses of the relation between patient and GP related factors and use of care. RESULTS--Compared with the period before stroke the use of care six months after stroke increased significantly, especially use of physical therapy, home help, and aids. Multivariate analyses showed that impaired functional health increased the use of care (range in odds ratios 1.6 to 6.7). Compared with younger patients, elderly patients were more likely to have home help (odds ratio 2.9) and aids (2.4) but less likely to receive therapy (0.4), psychosocial support (0.5), and an appreciable amount of care (0.5). Being female (1.7), living alone (4.0), and whether the GP was informed about patients' discharge (2.2) increased the use of home help. Higher financial income (2.8) and having a male GP (3.2) contributed to use of therapy. Emotional distress (1.6), living protected (3.2), and living alone (1.7) accounted for psychosocial support. CONCLUSIONS--Although older age, lower income, and poor discharge information to the GP decreased the use of some types of care, there is equity in access to care after stroke, primarily determined by needs in terms of functional health status and predisposing factors such as living arrangement and social circumstances. IMPLICATIONS--Patient oriented studies focusing on care processes and care outcomes in terms of subjective needs, perceived care deficits, and satisfaction with care are still required.     

Functional status of elderly home care users: do subjects, informal and professional caregivers agree?

Professional or informal proxy respondents are frequently used in surveys when physical or mental health may compromise the ability to participate or the quality of responses. Functional status (Katz activities of daily living [ADL], Lawton instrumental activities of daily living [IADL]) was assessed in a sample of 420 chronically dependent elderly receiving home care. Separate in-person interviews were conducted with subjects, main informal caregivers and professionals coordinating home care. We found substantial agreement (Kappa) particularly between subjects and informal caregivers in all ADL except continence and in all IADL except housekeeping. High levels of agreement were also found for cognitively impaired subjects (Mini-Mental State Examination <24). Disagreement was characterized by more frequent reports of dependence from informal and professional caregivers. Our data suggest that proxy responses by informal caregivers conform with answers provided by subjects but produce slightly higher estimates of dependence and that cognitively impaired elderly living in the community will provide accurate information on their functional status in most cases.     

A Description of the Health Needs of Elderly Home Care Patients with Chronic Illness

Although trends in health care point to the increasing use of home health services in caring for the chronically ill elderly, little attention has been focused on assessing the specific services that these patients perceive as most needed. Twenty eight elderly patients with chronic illness who had been referred for home health agency service self reported their functional status using items from the Barthel Index. These patients also ranked their perceived need for 32 home health services derived from the literature on a four point Likert scale. The items which averaged more than "little need" were: heavy lifting, assessment of a health condition, having questions answered, coordination of services, physical or occupational therapy, help obtaining special equipment, help organizing the home, checking on the elder, collecting laboratory specimens, teaching about diet and nutrition, referrals to community groups, help coping with stress or fears and companionship. There was a significant negative relationship between functional status scores and perceived needs (p < .05). Patients with higher functional status scores perceived less need for services. This data indicates that functional status measures are good indicators of the degree of perceived need for home health services. Continued research in home care is imperative if effective services aimed at the multiple needs of the chronically ill aging population and their families are to be developed.     

Home Health Care With Telemonitoring Improves Health Status for Older Adults With Heart Failure

Home telemonitoring can augment home health care services during a patient's transition from hospital to home. Home health care agencies commonly use telemonitors for patients with heart failure although studies have shown mixed results in the use of telemonitors to reduce rehospitalizations. This randomized trial investigated if older patients with heart failure admitted to home health care following a hospitalization would have a reduction in rehospitalizations and improved health status if they received telemonitoring. Patients were followed up to 180 days post-discharge from home health care services. Results showed no difference in the time to rehospitalization or emergency visit between those who received telemonitoring versus usual care. Older heart failure patients who received telemonitoring had better health status by home health care discharge than those who received usual care. Therefore, for older adults with heart failure, telemonitoring may be an important adjunct to home health care services to improve health status.     

Effects of using consumer and expert ratings of an activities of daily living scale on predicting functional outcomes of postacute care

To test the effects of using preference weights for activities of daily living (ADL) outcome measures derived from different sources, data from a large study of the outcomes of postacute care (PAC study) were analyzed using two different weightings for the ADL measures. Both were developed using the same magnitude estimation technique; one from a panel of long-term care experts (the expert rating system); the other from a group of elderly Medicare beneficiaries (the consumer rating system). Neither group was directly involved in the PAC study. Although ADL scores generated by both rating systems were highly correlated prior to hospitalization and at hospital discharge, the consumer and expert rating systems generated significantly different functional outcomes measured by the change of ADL scores with a few exceptions. Compared to the consumer rating system, the expert rating system generated a greater change in functional outcomes at each of three follow-up time points after hospital discharge. This study suggests that the choice of weights for ADL items is important.     

Discharge from hospital and its effect on surgical wound infections. The Israeli Study of Surgical Infections (ISSI).

A multicenter study of 2846 consecutive hernia operations was conducted to identify risk factors for infections that occurred during the hospitalization and post-discharge from hospital. Operated patients were followed-up for 30 days after surgery, whether at home or still hospitalized, and half the wound infection episodes were found to occur at home. Risk factors for both in-hospital and post-discharge infections seemed to be influenced by; (a) the selective nature of discharge, (b) the differential effect some risk factors had on either early or late infections. On any given day, patients selected by the clinical team to remain in hospital were more "at risk" for infection than those who left. As a result, they had a better chance of being diagnosed as infected during hospitalization. By contrast, those who were discharged home were perceived as low risk for complications. Subsequent infections in these patients occurred either due to factors "causing" late infections, therefore, unappreciated at the time of discharge, or unknown risk factors. More study risk factors were associated with in-hospital than with post-discharge infections, especially those associated with "early" infections. The implications of these findings for future evaluations of medical care in hospitalized patients are discussed.     

Functional capacity in two elderly populations aged 75 or over: comparisons at 10 years' interval

The functional capacity of two different non-institutionalized elderly populations and the resources available were compared in the same geographical area at 10 years' interval. The study shows that a 1.5-fold increase in the non-institutionalized population aged 75 or over combined with a fixed number of institutional beds in 10 years resulted in more disability among the elderly at home. The nursing home population at the latter point of time was older and showed a higher mortality, indicating increased pressure and selection to the nursing home. The first study comprised 82.8% and the second 89.2% of all community-living persons aged 75 or over. In 1988, the functional status of the aged living at home was significantly lower than in 1978, in 8 out of 12 functional activities of daily living (ADL). The Basic ADL Index decreased significantly both in men and in women, and mobility also deteriorated. The Instrumental ADL Index decreased significantly in men, while the Index was equally poor in women in both interviews. The poor functional status of the elderly in 1988 was accompanied by moving to the town centre and considerably improved housing standards. Home care services had more than doubled, and home nursing visits had also increased.     

Interests that occupy 86-year-old persons living at home: Associations with functional ability, self-rated health and sociodemographic characteristics

Background and Aims:  Interest is generated from the experience of pleasure in occupational behaviour. However, there is little known about the type and amount of interests that occupy very old people. The aims of the present study were to explore the interests of people aged 86 years who are living at home (n = 205) and to study the association between these interests and functional ability, self-rated health and sociodemographic characteristics.
Methods:  Participants were interviewed during home visits and data were analysed by using content analysis and statistics.
Results:  Participants had a broad range of interests. Personal and environmental factors played a part in people giving up their interests. Participants who regarded their health as good or who had no problems in carrying out daily activities had more interests than those with poor health or limited ability to participate in daily activities. Few differences based on gender and sociodemographics were found.
Conclusions:  Being active (i.e. practising many interests) also means experiencing good health. In the name of occupational justice, it is important to enable elderly persons to pursue interests.