Integrating an evidenced-based research intervention in the discharge of mental health clients

The purpose of this Canadian qualitative study was to explore the experiences of clinical staff who implemented a research intervention: the Transitional Discharge Model (TDM). The TDM provided mental health clients who were hospitalized with peer support and an inpatient staff member to bridge the therapeutic transitioning from hospital staff to the community care provider. Staff from three tertiary care mental health facilities in Canada identified their learning needs in regard to providing the intervention. An educational program was developed and delivered to the clinical staff to support and facilitate the implementation of the new TDM. The extent of the utilization of knowledge and implementation of the TDM varied across the three tertiary care mental health facilities. Focus groups (N=49) with clinical staff were conducted to explore various factors related to the training process as well as the challenges and benefits of implementing the TDM. Data were analyzed using Leininger's Phases of Ethnonursing Qualitative Data Analysis [Leininger, M. (2002). The theory of culture care and the ethnonursing research method. In M. Leininger & M. McFarland (eds.), Transcultural nursing: Concepts, theories, research, and practice (3rd ed.). New York: McGraw-Hill]. Findings revealed that clinical staff experienced challenges in roles and responsibilities, relationships with others, values and beliefs of clients, staff and community, resources, and the processes of care. From the findings, strategies were identified to support the integration of knowledge about the TDM into practice and to increase clinical staff's skills in implementing research interventions. These included support from others, as well as support of practice, policy, and education.     

Therapeutic relationships: from psychiatric hospital to community

The objective of this study was to determine the cost and effectiveness of a transitional discharge model (TDM) of care with clients who have a chronic mental illness. The model was tested in a randomized clinical trial using a cluster design. This model consisted of: (1) Peer support for 1 year and (2) Ongoing support from hospital staff until a therapeutic relationship was established with the community care provider. Participants (n = 390) were interviewed at discharge, 1 month post-discharge, 6 months post-discharge and 1 year post-discharge. Data collected included demographics, quality of life, health care utilization, levels of functioning and the degree of intervention received. The intervention group post-discharge costs and quality of life were not significantly improved compared with the control group. Although not predicted a priori, intervention subjects were discharged an average of 116 days earlier per person. Based on the hospital per diem rate this would be equivalent to 12M dollars CDN hospital costs. Both under-implementation among implementation wards and contamination in control wards were found. This study demonstrates some of the multiple challenges in health system research.     

Consumer feedback on nursing care and discharge planning

BACKGROUND: Gaining consumer feedback about nursing care and discharge planning is especially important given the changes that have occurred in acute inpatient mental health facilities. Consumers can best define the quality of the service they receive and surveys are considered to be good sources of information about nursing care and discharge planning. AIM: The aims of this study were to clarify consumer discharge needs, ascertain consumer perceptions of helpful practice, identify areas that require improvement, identify resources consumers deem important, ascertain satisfaction with specific aspects of services, and obtain baseline data to improve future discharge planning. METHOD: Satisfaction-with-services and discharge questionnaires were completed by clients (39 and 45, respectively) prior to discharge from three acute inpatient mental health units over a 2-month period. FINDINGS: Findings indicated that clients were most satisfied with the respect they received from staff, attention staff gave to concerns and worries, quality of service provided by nurses, way treatment met client needs and overall stay in hospital. The majority of respondents (95%) indicated that their discharge arrangements were explained to them and 90% were satisfied with these. Whilst over two-thirds indicated that the information provided in hospital to assist with discharge had been helpful, they highlighted some areas for service improvement. Resources to prepare them better for discharge included increased contact with consumer consultants and more information about mental health problems, medication and relapse prevention. CONCLUSION: This study constitutes another small step towards decreasing the gap between consumer expectations and actual treatment by asking consumers about their perceptions of discharge planning. The findings provide the basis for the development of more appropriate strategies to improve the continuity of services between hospital and community mental health settings.     

Needs assessment and discharge: a Scottish perspective

Discharge from hospital remains a difficult area for health services and it is unclear how much impact policy directives have had on discharge outcomes. The recent National Service Framework for mental health has highlighted discharge as a key area with Standard Five indicating minimum requirements at discharge from hospital. In order to aid this process this paper discusses the findings of a needs assessment of patients following discharge from psychiatric inpatient care in Scotland. The needs and unmet needs as assessed by both patients and mental health community staff on the Camberwell Assessment of Need (CAN) are presented. The CAN seeks to identify needs in a range of domains addressing basic, health, social, functioning and service issues. The sample comprised 173 patients recently discharged from acute psychiatric units in eight health board areas of Scotland and 98 community staff identified as providing key support to 98 of the patient sample. The findings indicate that the needs of patients discharged from hospital are complex and that the targeting of mental health services according to diagnostic criteria may not be the best way of ensuring support reaches those in most need. The range of needs identified suggests that fully integrated multidisciplinary care is essential to meet needs at discharge. The period initially after hospital discharge is one of vulnerability and incorporating a needs assessment into the discharge planning could aid the care planning process required by the Framework.     

The role of the hospital liaison nurse in effective discharge planning for older people: perspectives of discharge planners

The study identified effective discharge planning for older people from the perspectives of older people, their carers and nursing and social work discharge planners at a city hospital. This article discusses findings from the discharge planners who argued discharge planning was dependent upon effective communication between hospital and community staff, older people and their carers. They felt frustrated in their attempts to facilitate continuity of care within a casemix environment, and identified the pivotal role of the hospital liaison nurse in effective discharge planning. In addition, they called for ongoing reviews of hospital and community discharge planning practice, secondment of nurses between sectors to increase knowledge of other health services, and collaborative research.     

The effects of a transitional discharge model for psychiatric patients

This pilot randomized control trial was motivated by the discovery that many individuals with mental health problems are re-hospitalized within a year, with many being unable to fully adjust to community living. A solution was proposed in the form of an intervention called transitional discharge. The transitional discharge model included: (1) peer support, which is assistance from former patients who provide friendship, understanding and encouragement; and (2) overlap of inpatient and community staff in which the inpatient staff continue to work with the discharged patient until a working relationship is established with a community care provider. The overall aim of this study was to test the discharge model designed to assist patients discharged from acute admission wards to adjust to community living. This aim was tested through a number of related hypotheses, which suggest that, 5 months following discharge from an acute admission ward of a psychiatric hospital, individuals participating in a transitional discharge model: (1) report fewer symptoms; (2) report better levels of functioning; (3) have better quality of life; (4) are less likely to have been re-admitted to hospital. The study used a randomized experimental design with two conditions: experimental and usual treatment. In general, both the control and the experimental group demonstrated significant improvements in symptom severity and functional ability after 5 months. Usual treatment subjects in the control group were more than twice as likely to be re-admitted to hospital. This study needs to be replicated in Scotland with a larger sample and with a modified variation of the intervention called the Transitional Care Intervention.     

Nursing attitudes to the care of elderly patients at risk of continuing hospital care

This study assesses changes in nurses' attitudes to the process of decision-making regarding the care of elderly patients identified as being at risk of continuing (long-term) hospital care It was undertaken during the course of an evaluation of an intervention programme which involved a new approach to decision-making concerning the long-term care of dependent elderly patients Complementary components of the intervention programme were (a) an early discharge planning service, and (b) an extended home care programme The programme involved close liaison of specially trained community health nurses with staff members of the general medical wards of a large general hospital At the onset of the evaluation, it was perceived by management that the staff of the general medical wards favoured continuing hospital care for very dependent elderly patients rather than community care It was hypothesized that the intervention programme would result in a change in ward staffs' attitudes concerning the feasibility of home-based care and how decisions about care should be made To test this, attitude changes of community health nurses and ward nurses were assessed over the period of implementation of the programme Following the introduction of the programme, the study found that some of the ward nurses' attitudes became closer to those of community health nurses There was a shift in ward nurses' attitudes away from a professional approach to decisions about the care and placement of very dependent elderly patients to a 'patient choice' approach Nurses felt more strongly that they had an important role in patient care Implications of the research are considered in relation to the process of discharge planning     

‘Walking the tightrope’: The role of peer support workers in facilitating consumers’ participation in decision‐making

In adult mental health services, the participation of consumers is essential. The aim of this study was to explore the challenges faced by peer support workers when involving mental health consumers in decision‐making about their care and the strategies they employed to overcome these challenges so as to improve mental health consumers’ participation in decision‐making and recovery. Semi‐structured individual interviews were conducted with six peer support workers currently employed in psychiatric hospitals and/or community mental health systems. Thematic analysis identified challenges related to role definition, power imbalance, doctor‐centric medical approaches to care, and lack of resources. Strategies to overcome these challenges that were reported, included the following: facilitating meaningful involvement for service users, appropriate use of the lived experience, building relationships and communication, promoting rights and advocacy, and promoting professionalism of peer support workers (PSWs). Nursing staff need ongoing support and education to understand and value the varied roles of PSWs and thereby empower PSWs to engage in enhancing consumer decision‐making. The roles of the PSWs should be viewed as complementary, and greater appreciation and understanding of roles would better support recovery‐oriented care.     

Discharge planning: issues and challenges for gerontological nursing. A critique of the literature

Families are rapidly becoming unpaid givers of complex care. Using McKeehan & Coulton's systems model, this critique reviews the evolution of the structure and processes of discharge planning programmes. It explores three common assumptions: discharge planning programmes are cost-effective, allow for enhancement of patients' and families' quality of life, and ensure continuity of care between hospital and community. Funds are saved due to decreased lengths of initial hospital admissions and readmission rates. However, the cost of additional hospital and community resources is rarely considered. Little evidence supports the concept that discharge planning directly affects a patient's health status. Patients and families often do not perceive the same level of benefit from discharge planning as do health professionals. Several issues surrounding research methodologies used in the reviewed studies are identified. Of particular concern is the lack of qualitative research into patients' and families' experiences. The critique concludes with an exploration of ethical issues and challenges arising from increased emphasis on cost-effective discharge planning. These include patients' rights, provision of sufficient human, social and financial resources, improved hospital–community communications, and control over hospital-developed but community-implemented programmes.     

Getting it right: appropriate therapeutic recreation programs for community based consumers of mental health services

Over the last two decades in Australia, the deinstitutionalization process, which began with the intent of moving consumers of mental health services from in-patient facilities and then seeking to integrate these same individuals into the community, has served to highlight a wide range of consumer needs that have remained largely unfulfilled throughout the process. One such need has been the provision of appropriate therapeutic recreation programs for the community based consumers of the various state co-ordinated mental health services. This paper argues a case for a change in the approach which professional staff provide and lead therapeutic recreation based programs to enable participants to be empowered, rather than disempowered, through their involvement. Further, this paper contends that there is a need for health care staff, more generally, to accept the concept of such programs for the community based consumers of various mental health services as a valued one.     

Discharge of the older person from the emergency department - the perceptions of health professionals

Aims of study. This study aimed to examine the management of the older person in preparation for discharge home from an emergency department by exploring the perceptions of health professionals on procedures undertaken particularly in relation to the planned support, supply of medications, dressings, and contact information given to patients. An additional aim related to the perceived satisfaction levels of older patients and their carers. Background. It is imperative that older patients are adequately prepared for discharge home from the emergency department so as to avoid unnecessary anxiety, increase in health problems and possible re‐attendance or admission to hospital. Design. The sample in this study comprised the total population (n = 222) of all medical and nursing staff in both the emergency department and the primary care area. Methods. The method adopted was a survey approach which employed the use of standardized questionnaires comprising both open and closed questioning styles. Results. The data obtained identified results similar to previous research in that a discrepancy exists between hospital and community staff in relation to the procedures undertaken when discharging older people from the emergency department, such as arranging follow‐up care and appointments and giving the patient relevant contact numbers and dressings. Conclusion. The findings of this study support previous research in that there is a need to provide patients with planned support, aids and appliances, clear instructions and relevant contact numbers on discharge from the emergency department. Relevance to clinical practice. Good quality discharge planning is essential for a continuum of care for older people discharged from the emergency department. While patient education is often difficult in the busy emergency department, the provision of relevant information to older patients prior to discharge is essential particularly in relation to prescribed medications and wound care.     

Hospital discharge of older adults. How nurses can ease the transition

When an older adult is discharged from the hospital, she or he should have an individualized, comprehensive discharge plan to help prevent unnecessary complications and rehospitalization. But the large number of older adults who are hospitalized and their typically greater needs can make creating such a plan a challenge for clinicians. Clear communication among hospital personnel, patients, family members, case managers, and community caregivers (such as home health care nurses and long-term care staff) is essential. In examining effective discharge planning for this population, this article examines five discharge models.     

Consumer-orientated outcomes in discharge planning: a pilot study

? The desired outcome of health care provision can only be known by evaluating care from the perspective of the consumer. ? An exploratory study was undertaken to develop and evaluate a research instrument (a semistructured telephone interview guide) as a measure of patient outcomes in discharge planning. ? A sample of 29 patients was recruited from three medical wards of a large tertiary referral teaching hospital in Sydney, Australia. ? Participants were contacted at home after discharge from hospital and interviewed by telephone. Their perceptions of hospital discharge and continuing care needs were investigated. ? Preliminary analysis of the data obtained in the pilot study demonstrated that there were deficiencies in hospital discharge procedures which impacted on continuing care and that patients can contribute useful information for evaluating and improving discharge planning.     

Discovery of the discharge process: a study of patient discharge from a care unit for elderly people

Patient discharge is not a new research topic Numerous studies have shown patients do not always receive the services they need on leaving hospital The purpose of this study was to examine the process of discharge and move away from the snapshot study of discharge outcomes Interviews were undertaken with elderly patients, their carers and the hospital and community staff involved in their care A content analysis of the data revealed a distinctive discharge process which started with admission and ended with the patient leaving hospital Discharge planning was highlighted as a separate component of this process A number of examples are examined of how vulnerable to breakdown patient discharge can be     

Early discharge in acute mental health: A rapid literature review

Long psychiatric hospital stays are unpopular with services users, harmful, and costly. Economic pressures alongside a drive for recovery‐orientated care in the least restrictive contexts have led to increasing pressure to discharge people from hospital early. Hospital discharge is, however, complex, stressful, and risky for service users and families. This rapid literature review aimed to assess what is known about early discharge in acute mental health. Searches were conducted in nine bibliographic databases, reference lists, and targeted grey literature sources. Fourteen included papers focused on early discharge in mental health, a population over 18 years with a mental health condition, and reported outcomes on therapeutic care or service delivery. Quality appraisal was undertaken using The Mixed Method Appraisal Tool. The meta‐summary of the literature found that early discharge was neither provided to all inpatients nor limited to the Crisis Resolution and Home Treatment (CRHT) service model internationally. Early discharge interventions required collaborative working and discharge planning. It was not associated with unplanned readmissions and had a small effect on length of stay. Most studies reported service outcomes, whereas health outcomes were underreported. Professionals and service users were positive about early discharge and service users asked for peer support. Carers preferred hospital or day hospital care suggesting their need for respite. Limitations in the scope, detail, and quality of the evidence about early discharge leave an unclear picture of the components of early discharge as an intervention, its effectiveness, cost‐effectiveness, or outcomes.     

Bridging the discharge process: staff and client experiences over time

Before the “Bridge to Discharge” innovation, hospital and community services were largely separate, and the consumer group was rarely included in direct clinical issues. The “Bridge to Discharge” project involves a partnership among a psychiatric hospital schizophrenia program, a public health program, and a consumer group to assist individuals who had experienced lengthy psychiatric admissions reintegrate into the community. This article reports the qualitative evaluation of client and staff responses every other month regarding the changes in this project. Clients described “hope” for a life outside the hospital and the importance of working with staff they knew. Role changes for both the inpatient nurses and the public health nurse reflect role expansions and a broader attention to client issues. Partnerships among hospital, community, and consumer groups have the potential to assist clients to make the transition to successful community living. Understanding the changes over time resulting from innovations will assist nurses and others in planning for appropriate services and supports.     

Peer support. An under-recognized resource in cardiac recovery.

BACKGROUND: Cardiovascular disease remains the leading cause of mortality and premature death in western societies. Thus, rates of interventions such as coronary artery bypass surgery are continuing to grow. Health care reform and initiatives to reduce health care expenditures have resulted in early patient discharge from hospital following cardiac surgery. With subsequent cutbacks in nursing support and community-based care, patients are leaving hospital less prepared and supported to deal with the changes that occur during the first weeks of recovery. AIMS: To examine the theoretical assumptions that support the contention that peer support is an under-utilized resource for patients who are recovering from cardiac surgery and the challenges to evaluating peer support interventions. METHODS: A review of current literature, which focuses on cardiac surgery recovery, transitions, social support, and peer support interventions. RESULTS: Peer support (lay assistance from individuals who possess experiential knowledge and similar characteristics), a form of social support, is a viable and potentially sustainable mechanism to put in place during transitional life events such as recovery from cardiac surgery. CONCLUSIONS: Further investigation is needed of peer support interventions for cardiac surgery patients. Specifically, investigations of the influence of peer support interventions on recovery and health outcomes are necessary in this patient population. Yet, challenges exist to undertaking well-designed investigations of social interventions such as peer support.     

Needs assessment and staff education to effect long-term change in emergency medicine in rural Nepal

Medical work in developing countries is challenging and rewarding. To make a lasting impact on the local community, a health care worker must be willing to listen to the needs of the people. The long-term impact of a needs assessment and staff education on emergency medicine at a rural hospital in Nepal is presented. The Scheer Memorial Hospital is a 102-bed non-governmental, not-for-profit hospital in Banepa, Nepal. Nepalese and ex-patriot health care professionals staff the hospital. Medical supplies are obtained from local manufacturers or as donations from foreign organizations. The hospital waives fees for those who cannot afford care. Two academic emergency physicians with expertise in international health undertook a needs assessment to assist in planning for long-term health care goals related to emergency medicine. The assessment focused on health care planning and education of the local health care staff. Based on interviews and objective assessments, a plan was developed and implemented to address 4 key areas: physical plant, equipment, staff training and essential tasks. Sustainable positive change was accomplished by acknowledging local customs and standards of care, meeting the needs of local health care staff and using available resources.     

Characteristics of older adults rehospitalized within 7 and 30 days of discharge: implications for nursing practice

Rehospitalization within 30 days consumes a significant portion of health care costs; therefore, interventions aimed at reducing the risk of rehospitalization are needed. A retrospective study was conducted examining rehospitalization rates and diagnoses according to discharge location and comparing characteristics of older adults within 7 and 30 days of discharge from a community hospital. Data on rehospitalization for Medicare fee-for-service patients (75 and older) over a 12-month period were obtained from the information technology department of a not-for-profit community hospital. A total of 6,809 patients were discharged, with 12% rehospitalized within 30 days. Skilled nursing facilities had the highest rehospitalization rates (15%), followed by home with home health care (13%) and then home with self-care (8%). The highest rehospitalization rates were in areas where nursing has a strong presence, suggesting that nurses can play an important role in the development of interventions aimed at reducing rehospitalizations.     

Clients with intellectual disabilities on psychiatric units: care coordination for positive outcomes

The transition from residential facilities to and from the psychiatric hospital setting is difficult for individuals with intellectual disabilities (ID). In the U.S.A., specialized psychiatric units for individuals with ID are uncommon and this population is usually served in generalized services. Nevertheless, providers of mental health services in the U.S.A. receive little training in their specific needs. Best practices call for coordination of plans between psychiatric units and community agencies, multidisciplinary care plans, staff education and comprehensive discharge planning in order to improve outcomes of psychiatric hospitalization. An inner city psychiatric unit in a major academic medical centre and a community agency providing residential care for individuals with ID cooperated to provide a plan of care for a client with ID both for hospitalization and for discharge leading to improved outcomes.