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Question: My elderly Mom was recently admitted into the hospital (the reason isn’t relevant). It seemed as soon as we got her settled in, everyone started talking about planning for her “discharge.” She just got there! Why was everyone so focused on getting us out?
Answer: Your mother must have felt like she was on the receiving end of that old joke: “Here’s your hat, what’s your hurry?”
But her experience isn’t all that unusual. The length of time that the average patient stays in a hospital has been getting shorter and shorter. So hospitals are trying to get an early start on the task of preparing patients for their discharge.
Many years ago, a patient might have spent weeks in hospital convalescing. Today, they are often sent home within a few days – even after major surgery.
“The average length of stay if you were acutely ill was almost 10 days a decade ago – and now it’s down to five,” says Lois Fillion, director of operations for the community program at Sunnybrook Health Sciences Centre.
There are many reasons for shorter hospital stays. Changes in medical technology have played a significant part. “Laparoscopic surgery and other technological advances have been a major game changer,” explains Dr. Joshua Tepper, president of Health Quality Ontario, an arms-length provincial agency.
With this type of minimally-invasive operation, surgeons insert their instruments through tiny puncture holes and use miniature cameras to see what they are doing inside the body. There are no big incisions. As a result, recovery times are much faster than they used to be. Patients can often go home in just a few days and many don’t spend a single night in a hospital bed.
There has also been a very deliberate effort in Ontario, and many other jurisdictions, to have hospitals focus primarily on acute-care situations such as surgeries and medical emergencies. The goal is to have most other health-care services provided in the community – or even in the patient’s own home. That means many patients now leave the hospital as soon as they are medically able to do so.
To meet this goal, there has been a slow but steady redistribution of health-care resources. Acute-care hospital beds have been trimmed back. At the same time, there’s been an investment in primary care, local health clinics, rehabilitation facilities, long-term-care beds and home care. Increasingly, nurses and occupational therapists are going to the patients’ homes to tend to certain needs.
“People, for the most part, would rather be in their own homes. Being in hospitals can also have risk such as hospital-acquired infections and it is generally better for patients to be at home as soon as appropriate,” says Dr. Tepper.
“There is also a realization that it is often more economically efficient to provide care outside of the hospital. The cost of a bed in a hospital is quite high and you can provide home care and other care in the community at a lower cost,” he adds.
Going home early can be a good thing provided the proper community supports are in place and patients – or their family members – know what to do. If a patient has a setback, and ends up in the emergency department, that defeats the purpose of an early discharge.
Hospitals have developed various strategies to help prepare patients for the transition back home.
As you noticed in your mother’s case, that process seems to start almost as soon as the patient arrives. “A lot needs to happen in a very short amount of time,” Lina Gagliardi, the professional leader for social work at Sunnybrook, says in explaining the apparent rush.
And hospitals are frequently trying new things to see if the discharge process can be improved. Sunnybrook, for instance, recently launched an online survey to seek feedback from patients and family members. (You, too, can complete the survey, which is posted on Sunnybrook’s website.)
“We would like to improve the dialogue between the health-care team and patients and their families,” says Ms. Gagliardi, who is also an adjunct lecturer in the Faculty of Social Work at the University of Toronto.
After all, communication is the key to a smooth discharge. For patients, the list of “Do You Know?” and related questions can be fairly long:
- Do you know how you will get home on your day of discharge? Is a family member or friend picking you up?
- Do you know how to manage your own health care at home? That might include knowing how to change a bandage or what rehab exercises to do.
- Do you know how and when to take your medications? Are you aware of any potential side effects and what to do if they occur?
- Do you know when you should connect with your family doctor to make sure your recovery is on track?
- Do you know whom you should contact at the hospital if you have a follow-up question about your care?
- Do you need additional help when you get home? Do you need to call on family or friends to lend a hand?
- Do you need special medical supplies or equipment at home to aid recovery?
- If you’re eligible for home care, and it’s been arranged for you by the hospital before your discharge, do you know whom to call if the help doesn’t show up? (In Ontario, those services are usually provided through a local Community Care Access Centre or CCAC.)
So, there are many forces nudging us to shorter hospital stays. And there are lots of justifiable reasons to get discharge planning under way as soon as possible.
However, there are still some patients who are getting stuck in transition. They’re well enough to leave the hospital but not able to manage on their own. Or, their families are incapable of looking after them – even with some assistance from publicly-funded home care.
“They are frail and elderly and often have some form of cognitive impairment. They are challenging cases,” says Ms. Fillion.
“They don’t need the intensity of resources of an acute-care [hospital] facility. What’s needed is an alternative level of care,” she explains.
“That could be rehabilitation, complex continuing care, convalescent care or a nursing home.”
Despite some investments in these facilities, “the resources for the magnitude of what we are dealing with right now do not appear to be there,” says Ms. Fillion.
In other words, the alternative level of care system hasn’t been keeping pace with the growing demand for those services. It’s a gap that will need to be filled before the vast bulk of the baby-boom generation reaches old age – which isn’t very long from now.
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca and follow Paul on Twitter @epaultaylor
The comments section is closed.
It is good practice to begin the assessment process early to aid in the transitions in care planning. It is relatively easy if a person is having an elective surgery as some plans are made for discharge prior to admission such as in the pre-admission clinic.
However, for medical patients admitted through emergency departments we have to be careful to know the underlying reason a person is admitted to hospital. For example with a patient who is experiencing cognitive and functional decline healthcare providers need to know are they exhibiting signs of dementia or experiencing delirium due to sepsis.
The risk is that starting a plan too early can put the patient and their family (SDMs) through an upheaval of difficult plans only to be revised when the diagnosis is clear. Certainly quality assessments of the patient’s pre-admission functional, social and level of community support is helpful to diagnosis and to creating the transition plan but a definitive plan cannot be created until the illness trajectory is better known.
Approached from the perspective of quality assessments discharge planning is not rushed if begun early, but planned well and appropriately. If the transitions in care plan is not known, early planning can give patients and their families the security that they are not alone navigating a complex series of providers to create the best plan for the patient.