NIHR Signal Personal discharge plans may lead to shorter hospital stays and fewer readmissions

Published on 23 March 2016

Personal discharge plans for medical patients are likely to result in slightly shorter hospital stays of less than a day and a lower risk of unplanned readmissions for many people, according to a systematic review published by the Cochrane Collaboration.

The review looked at the effect of personal discharge plans for people leaving hospital to go home or to residential care. However, it is unclear from this evidence what impact there was on patient outcomes or healthcare costs.

The findings of this high quality review generally support NICE guidelines on the importance of personal discharge planning.

Personal discharge plans may lead to shorter hospital stays and fewer readmissions

Why was this study needed?

In 2015, an estimated 1,500 delays in discharge from hospital occurred every day, as calculated by NICE from NHS England figures. Reasons for delay included waiting for patient assessments, and lack of organisation of post-discharge health and social care arrangements. Inadequate home support after hospital discharge can lead to readmission. In 2013 there were more than a million emergency readmissions within 30 days of discharge, at a cost to the economy of £2.4 billion.

Personal discharge plans, in which multidisciplinary teams assess patient needs and plan safe and timely transfer of care, aim to reduce unnecessary delays in leaving hospital and unplanned readmissions. However, discharge procedures vary between departments and healthcare professionals in the same hospital. This review assesses the effectiveness of discharge plans for different groups of patients.

This study is an update of a Cochrane review last published in 2013. Cochrane reviews are carried out to a high standard and the main results were based on moderate quality evidence so we can be confident in the findings.

What did this study do?

The review compared the effectiveness of personal discharge planning with routine discharge procedures that are not tailored to individual patients. It looked at whether discharge planning affected length of stay in hospital, unscheduled readmission rates, satisfaction and healthcare costs.  

The 30 included trials (including six new to this update) covered 11,964 people.

The review grouped the studies according to whether they were of elderly medical patients, patients recovering from surgery or a mix of both. More than half of the patients in the included studies were over 70 years old. For 19 of the studies, results were pooled. Separate analyses were done for people admitted to hospital after a fall and those in a mental health unit.

Cochrane reviews are carried out to a standard, high quality approach. However applicability of findings to the NHS is reduced as most of the studies took place in North America which has a different insurance based health system in which most people enter residential homes as private payers. Four studies were conducted in the UK. Two did not describe ‘usual care’ for the control group.

What did it find?

  • In 12 trials of people in hospital with a medical condition, those allocated discharge planning compared with no planning, had a slightly shorter hospital stay (mean hospital stay 0.73 days shorter, 95% confidence interval [CI] -1.33 to - 0.12). The evidence was of moderate quality.
  • In 15 trials of people admitted with a medical condition, those with a discharge plan were 13% less likely to be readmitted within three months of discharge (relative risk [RR] 0.87, 95% CI, 0.79 to 0.97). The evidence was of moderate quality.
  • It was unclear if discharge planning reduced readmission rates in people admitted to hospital after a fall (RR 1.36, 95% CI 0.46 to 4.01). The two trials reviewed were very low quality.
  • It is uncertain if discharge planning for patients with a medical condition makes any difference to the cost of care. The five studies which looked at this were very low quality.

What does current guidance say on this issue?

The NICE 2015 guideline on hospital discharge for adults with social care needs says that from admission or earlier, hospital and community based multi -disciplinary teams should agree a discharge plan which takes account of the person’s social and emotional wellbeing as well as the practicalities of daily living.

NICE says that while its guideline is likely to have resource implications, overall it is likely to be cost saving. The savings will come from reduced admission tariff payments and bed days avoided.

What are the implications?

Moderate certainty evidence from this high quality review supports NICE guidelines on the benefits of discharge planning, although whether costs are reduced is uncertain. NICE says that even a small reduction in length of stay would free up capacity for subsequent admissions.

The authors suggest more research is needed on the quality of communication between hospital and community services, an area not covered by this review.

The Better Care Fund, announced by the government in June 2013 has £5.3bn to ensure a transformation in health and social care. The pooled budget provides incentives for the NHS and local government to work more closely together to improve integration of health and social services. Other relevant work includes new models of care under the Five Year Forward View to promote better integration across health and care organisations.   Providers of health and social care may also be interested in developing this potential intervention so that the barriers to timely discharge from hospital care can be reduced further.

Citation and Funding

Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;(1):CD000313.

No funding information was provided for this study.

Bibliography

National Audit Office. Emergency admissions to hospital: managing the demand. London: National Audit Office; 2013.

NHS England. Delayed transfers of care [internet]. Leeds: NHS England; 2016.

NHS England. Better Care Fund planning [internet]. Leeds: NHS England; undated.

NICE. Transition between inpatient hospital settings and community or care home for adults with social care needs. NG27. London: National Institute for Health and Care Excellence; 2015.  

NICE. Costing statement: Implementing the NICE guideline on Transition between inpatient hospital settings and community or care home settings fo9r adults with social care needs. NG27. London: National Institute for Health and Care Excellence; 2015.

Why was this study needed?

In 2015, an estimated 1,500 delays in discharge from hospital occurred every day, as calculated by NICE from NHS England figures. Reasons for delay included waiting for patient assessments, and lack of organisation of post-discharge health and social care arrangements. Inadequate home support after hospital discharge can lead to readmission. In 2013 there were more than a million emergency readmissions within 30 days of discharge, at a cost to the economy of £2.4 billion.

Personal discharge plans, in which multidisciplinary teams assess patient needs and plan safe and timely transfer of care, aim to reduce unnecessary delays in leaving hospital and unplanned readmissions. However, discharge procedures vary between departments and healthcare professionals in the same hospital. This review assesses the effectiveness of discharge plans for different groups of patients.

This study is an update of a Cochrane review last published in 2013. Cochrane reviews are carried out to a high standard and the main results were based on moderate quality evidence so we can be confident in the findings.

What did this study do?

The review compared the effectiveness of personal discharge planning with routine discharge procedures that are not tailored to individual patients. It looked at whether discharge planning affected length of stay in hospital, unscheduled readmission rates, satisfaction and healthcare costs.  

The 30 included trials (including six new to this update) covered 11,964 people.

The review grouped the studies according to whether they were of elderly medical patients, patients recovering from surgery or a mix of both. More than half of the patients in the included studies were over 70 years old. For 19 of the studies, results were pooled. Separate analyses were done for people admitted to hospital after a fall and those in a mental health unit.

Cochrane reviews are carried out to a standard, high quality approach. However applicability of findings to the NHS is reduced as most of the studies took place in North America which has a different insurance based health system in which most people enter residential homes as private payers. Four studies were conducted in the UK. Two did not describe ‘usual care’ for the control group.

What did it find?

  • In 12 trials of people in hospital with a medical condition, those allocated discharge planning compared with no planning, had a slightly shorter hospital stay (mean hospital stay 0.73 days shorter, 95% confidence interval [CI] -1.33 to - 0.12). The evidence was of moderate quality.
  • In 15 trials of people admitted with a medical condition, those with a discharge plan were 13% less likely to be readmitted within three months of discharge (relative risk [RR] 0.87, 95% CI, 0.79 to 0.97). The evidence was of moderate quality.
  • It was unclear if discharge planning reduced readmission rates in people admitted to hospital after a fall (RR 1.36, 95% CI 0.46 to 4.01). The two trials reviewed were very low quality.
  • It is uncertain if discharge planning for patients with a medical condition makes any difference to the cost of care. The five studies which looked at this were very low quality.

What does current guidance say on this issue?

The NICE 2015 guideline on hospital discharge for adults with social care needs says that from admission or earlier, hospital and community based multi -disciplinary teams should agree a discharge plan which takes account of the person’s social and emotional wellbeing as well as the practicalities of daily living.

NICE says that while its guideline is likely to have resource implications, overall it is likely to be cost saving. The savings will come from reduced admission tariff payments and bed days avoided.

What are the implications?

Moderate certainty evidence from this high quality review supports NICE guidelines on the benefits of discharge planning, although whether costs are reduced is uncertain. NICE says that even a small reduction in length of stay would free up capacity for subsequent admissions.

The authors suggest more research is needed on the quality of communication between hospital and community services, an area not covered by this review.

The Better Care Fund, announced by the government in June 2013 has £5.3bn to ensure a transformation in health and social care. The pooled budget provides incentives for the NHS and local government to work more closely together to improve integration of health and social services. Other relevant work includes new models of care under the Five Year Forward View to promote better integration across health and care organisations.   Providers of health and social care may also be interested in developing this potential intervention so that the barriers to timely discharge from hospital care can be reduced further.

Citation and Funding

Gonçalves-Bradley DC, Lannin NA, Clemson LM, Cameron ID, Shepperd S. Discharge planning from hospital. Cochrane Database Syst Rev. 2016;(1):CD000313.

No funding information was provided for this study.

Bibliography

National Audit Office. Emergency admissions to hospital: managing the demand. London: National Audit Office; 2013.

NHS England. Delayed transfers of care [internet]. Leeds: NHS England; 2016.

NHS England. Better Care Fund planning [internet]. Leeds: NHS England; undated.

NICE. Transition between inpatient hospital settings and community or care home for adults with social care needs. NG27. London: National Institute for Health and Care Excellence; 2015.  

NICE. Costing statement: Implementing the NICE guideline on Transition between inpatient hospital settings and community or care home settings fo9r adults with social care needs. NG27. London: National Institute for Health and Care Excellence; 2015.

Discharge planning from hospital

Published on 28 January 2016

Goncalves-Bradley, D. C.,Lannin, N. A.,Clemson, L. M.,Cameron, I. D.,Shepperd, S.

Cochrane Database Syst Rev Volume 1 , 2016

BACKGROUND: Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review. OBJECTIVES: To assess the effectiveness of planning the discharge of individual patients moving from hospital. SEARCH METHODS: We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov). SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients. DATA COLLECTION AND ANALYSIS: Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text. MAIN RESULTS: We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD - 0.73, 95% CI - 1.33 to - 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials). AUTHORS' CONCLUSIONS: A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.

The review authors analysed studies of discharge planning by the following steps:

  • pre-admission assessment (where possible);
  • case finding (actively searching for people likely to be at increased risk) on admission;
  • inpatient assessment and preparing a discharge plan based on individual patient needs. This could include multidisciplinary assessment involving the patient and their family, and communication between relevant professionals within the hospital;
  • implementing the discharge plan. This should be consistent with the assessment and record the discharge process;
  • assessing whether the discharge plan was carried out.

Expert commentary

In this review of individualised patient discharge plans studies were excluded where any standardised (i.e. non-individualised) interventions were a feature of the discharge plan. But policy guidelines currently advocate standardised discharge checklists and some universal assessments. So this is a review that may extend current practice.

The effectiveness of communication was not a feature reported within the trials under review, this despite being a pivotal factor in the planning of discharge.

While elements within ‘an individual’s discharge plan’ vary according to its complexity, the review of plans according to phases of the discharge process is beneficial for practice.

Liz Deutsch, Consultant Nurse (acute medicine), Heart of England NHS Foundation Trust, Birmingham. Clinical Doctoral Research Fellowship (NIHR) University of Manchester.

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