Comparing Two Models of Discharge Planning Rounds in Acute Care Patricia A. O'Hare
Rounds are a primary part of the discharge planning process in acute care hospitals. The multidisciplinary aspect of rounds has been accepted as a given, but the differences resulting from differently composed interdisciplinary groups functioning in rounds has not been investigated. This experimental study examined two models of discharge planning rounds and compared their effects on the process of probing, identifying, planning for, and following through on patient discharge needs. Copyright © 1992 by W.B. Saunders Company
ISCHARGE PLANNING has taken on new importance for both professionals and consumers in today's fiscally constrained health care environment. In the acute care setting, the inclusion of the discharge planning process as a Medicare "condition of participation" has been mandated by legislation and subsequent regulations (Omnibus Budget Reconciliation Act, 1986). The Joint Commission on Accreditation of Healthcare Organizations in their 1989 Accreditation Manual for Hospitals included standards that require a hospital to establish a formal discharge planning process (Nash, 1988). Discharge planning rounds are a case-finding, coordination, and communication mechanism in the discharge planning process; various health care providers meet on a regularly scheduled basis, usually weekly, to review the current status of all patients on a particular unit (Discharge Planning Models, 1983; Kerstein, Baker, & Maguire, 1985). It is specifically through the rounds that provider interaction can occur on a scheduled basis, with planning carried out in a timely manner based on the patient's condition and
D
From the School of Nursing, Georgetown University, Washington, DC. Patricia A. O'Hare, DrPH, hiS, RN: Assistant Professor of Nursing, Georgetown University School of Nursing, Washington, DC, and currently a Postdoctoral Fellow in Psychosocial Oncology, Unh'ersity of Pennsyh'ania School of Nursing, Philadelphia, PA. This research was supported by a Predoctoral National Research Service Award (NRSA) Nurse Fellowship from the DHHS, PHS, HRSA, #SF-31-NU-05398-15. Address reprint requests to Patricia A. O'Hare, DrPH, MS, RN, 13026 Victoria Heights Dr, Bowie, MD 20715. Copyright © 1992 by W.B. Saunders Company 0897-1897/92/0502-001055.00/0
66
identified needs. Routine rounds provide an opportunity for early and continuous assessment, adequate planning, and referral. These rounds also provide the occasion for determining and documenting which patients do not require discharge planning assistance. The size and composition of the rounds team are structural features worthy of study. The size and composition of the rounds team may affect identification of needs, receipt of services, and overall use of hospital services. No evaluative research of discharge planning team rounds, either process or composition, has appeared in the literature. Therefore, this experimental study tested two models of discharge planning rounds in an acute care community teaching hospital and compared their effects on the process of probing, identifying, planning for, and following through on patient discharge needs. BACKGROUND
Bristow, Stickney, and Thompson (1976) have written that regular discharge conferences should be held on each unit with the "full range" of professionals represented. Chakrabarty, Beallor, and Pelle (1988) state that, "Generally, the continuing care planning team will consist of representatives from social services, nursing, medicine, nutrition, physical therapy, occupational therapy, speech therapy, and home care. The composition of the team may vary depending on the intensity of services required in moving the patient from one level of care to another" (p. 154). Interdisciplinary discharge planning team meetings are the formal structure described in the literature but the "empirical evidence concerning the effect of group size Applied Nursing Research, Vol. 5, No. 2 (May), 1992: pp. 66-73
67
ACUTE CARE DISCHARGE PLANNING ROUNDS
on actual productivity is highly fragmented and incomplete" (Steiner, 1972, p. 89). Various models of the size and composition of the rounds team have been described in the literature ranging from one or two providers (Morgan, 1973; Previte, 1979; Reichelt & Newcomb, 1980) to a multidisciplinary team. This multidisciplinary team could be composed of the physician (resident oi" attending), head nurse on the unit, other nursing staff, social worker, dietician, physical therapist, pharmacist, community health nursing consultant, utilization review coordinator, home care department representative, pastoral care department representative, and possibly other professionals (Arenth & Mamon, 1985; Chakrabarty et al., 1988; Edwards, 1978; Fortune, 1981; LeMontagne & McKeehan, 1975; Willard & Kasl, 1972). An important issue is what effect, if any, does the size and composition of the rounds team have on identifying, assessing, and planning for resources to meet a patient's continuing care needs at discharge. As Steiner (1972) noted, " . . . if a group is already large enough to possess all the relevant resources needed to perform a task well, the addition of new members may cause process losses without adding anything whatever to potential productivity" (p. 82). Donabedian's (1978) conceptual framework of structure, process, outcome was used for this study. It was postulated that structural characteristics of the health care delivery system, namely the size
A basic group of three providers (experimental group) participating in rounds were compared with a larger group of six providers (control group).
charge planning was defined by the number of needs probed, identified, planned for, and followed through on in the rounds. The greater the number of needs discussed, the more effective the discharge planning. METHODS
An experimental crossover design was used to test two models of discharge planning in an acute care community teaching hospital. With the crossover design, both the intervention and the control or usual treatment were able to be measured on both sides of the hospital during the time of the study. Each hospital side therefore acted as its own control in terms of confounding factors such as unit staff differences. A basic group of three providers (experimental group) participating in rounds were compared with a larger group of six providers (control group). The three-provider model (experimental) consisted of the nurse on the unit, the social worker assigned to the unit, and the discharge planning nurse coordinator. The six provider model (control) consisted of the nurse on the unit, social worker assigned to the unit, discharge planning nurse coordinator, health promotion coordinator, dietician, and a pastoral care department representative. In this study, the health promotion coordinator was a registered nurse with a master's degree in nursing and 5 years of clinical experience including patient and staff education. The discharge planning nurse coordinator was baccalaureate prepared and had practiced in home health. The social workers had master's degrees. The registered nurses on the units were educationally prepared at the diploma or associate degree levels; a few were baccalaureate nursing graduates. The dieticians were registered dieticians. The representatives from the pastoral care department were all members of religious orders with varying backgrounds and preparation. PROCEDURE
and composition of the group for the discharge planning rounds, would effect the discharge planning process. Ultimately, the process effects the outcomes, such as teaching and referrals, to meet those discharge needs. Thus, the purposes of this study were to determine which professionals and how many providers need to be involved in rounds for effective discharge planning. Effective dis-
The study had three phases. These phases were baseline (pre-experimental) and two intervention periods. Two sides of a 355-bed community teaching hospital were used for the study. Each side included a medical, surgical, and medical/surgical unit; the two sides of the hospital were functionally separate. Equivalency of the two sides were tested at baseline and in both intervention periods; the
PATRICIA A. O'HARE
68
sides were found to be similar. Thus, there was no selectivity in terms of the kinds of patients admitted to one side or the other from acuity or reimbursement perspectives. The intervention was the use of a three-provider group in the rounds. Randomization was by hospital side. The crossover design was used to allow both sides of the hospital to be exposed to the intervention. In other words, the side of the hospital that was randomly assigned as the experimental group during intervention period one became the control group during intervention period two and vice versa. During the pre-experimental baseline period, the discharge planning rounds were conducted in the usual way with the six providers. The pre-experimental period was 5 weeks and data were collected on 139 patients. Data were collected on 246 patients during intervention time one and on 260 patients during intervention time two. Each intervention phase was 9 weeks with a recovery period of 8 weeks separating the two intervention phases. The recovery period was to decrease the crossover effect from the previous time period. The study was performed at weekly interdisciplinary continuity of care rounds on two sides of the hospital. Patients were included in the sample if they (a) were discussed at rounds at least one time; (b) had a hospital length of stay of 5 to 31
Effectiveness of the discharge planning rounds was measured by the number of patient discharge needs probed, identified, planned for, and followed through on in the rounds process. days; and (c) were in one of six broad diagnostic categories. The diagnostic categories included cancer, diabetes, diseases of the blood vessels, heart, respiratory system, and chronic renal failure. Selection of the diagnostic categories was based on the rationale that these diagnosis-related groups were likely to have more need for discharge planning due to the recuperative period or chronicity of the disease (Anderson & Steinberg, 1985; Donabedian & Rosenfeld, 1964; Fethke, Smith, &
Johnson, 1986; Gooding & Jette, 1985; Holloway, Thomas, & Shapiro, 1988; Kark & Hopp, 1970; Lindenberg & Coulton, 1980; Zook, 1980). INSTRUMENT
Effectiveness of the discharge planning rounds was measured by the number of patient discharge needs probed, identified, planned for, and followed through on in the rounds process. The data collection methods were observation and tape recording of the rounds and a chart audit after the patient was discharged. A structured instrument (Figure 1) was used to measure the process. The operational definitions of the process were as follows: 1. Probed. The providers participating in the rounds asked questions regarding the particular need to determine if the need was present or not. 2. Identified. The determination by one or more providers that such a need was present. 3. Planned. The decision, by the providers participating in the rounds, as to how an identified or potentially identified need would be met. 4. Followed through. The fact that the need was met. This completed the process and included statements at rounds that a task to meet a need had been performed. It was also expected that outcomes would be documented in the patient's chart. For example, the outcomes documented were that referrals to other disciplines or agencies had been made, literature had been distributed, and/or classes has been attended. A separate data collection form was used for each patient discussed who met the criteria for inclusion in the study. The unit of analysis was patient needs. The instrument was scored by summing the individual need categories so that a measurement of the total number of needs that were probed, identified, planned for, and followed through on was obtained. These numbers were so small that it was decided to include a need as discussed even if only one part of the process from probing to following through was achieved. If the patients included in the study were discussed at rounds more than one time, a new data collection form was used for each week. The data were then combined for all rounds for each study patient at the time of coding and data entry into the computer file. A separate data collection form was used for each patient to record the discharge planning pro-
Unit: Housing and Social Sit.
Study No.
Date of Rounds Diagnoses.
NEEDS ASSESSMENT TOOL FOR RECORDING CONTENT OF ROUNDS AND MEDICAL RECORD Need Areas Disch. Date Disc?
Probed by whom
Identified by whom
Planned by whom
Followed Through On Met by How whom
HOUSING FINANCES NURSING CARE ° Community Nursing 1. 2. 3. 4.
Skilled/Care/Procedures Follow-Up Teaching Follow-Up Supervision Other
HEALTH EDUCATION 1. 2. 3. 4. 5.
Knows Diagnosis Understands Diagnosis Will Attend Classes Will Receive 1-1 Teaching Family/SO Will Attend 6. Family/SO 1-1 Teaching 7. Other PSYCHOSOCIAL PROBLEMS ASSOC. WITH ILLNESS/DISABILITY 1, Counseling (Pt/Family) 2. Ref. to Self-Help Grp (PtJF) 3. Ref. to Supportive Vol (PtJF) 4. Other NUTRITIONAL 1. Arrange Meals on Wheels 2. Homemaker Prepare Meals 3, Food Stamps 4. Other ASSISTANCE WITH PERSONAL CARE ASST. WITH CARE OF ENVIRONMENT EQUIPMENT/SUPPLIES REHABILITATION: PT; OT; SPEECH TRANSPORTATION MEDICAL CARE TOTAL
Figure 1. Data collection tool. From Examining the Discharge Planning Process: An Evaluation of Two Models in an Acute Care Community Hospital, (Doctoral Dissertation, The Johns Hopkins University}. Copyright © 1984 by Patricia A. O'Hare.
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70
cess as documented in the chart. Chart documentation of the process as compared with the rounds process is discussed in another manuscript in preparation. The structured instrument consisted of 12 need categories (Figure 1). These categories were determined from the literature (Lindenberg & Coulton, 1980) and the knowledge and experience of the investigator. Nurses and social workers also reviewed the instrument before and after the data collection for clarity and consistency with categories represented in the literature. This structured data collection instrument has face validity and content validity. All the data for the study were collected by the investigator. Fifteen percent of the data were reviewed by an independent reviewer for inter-rater reliability. This independent reviewer was a master's student in medical-surgical nursing who was trained by the investigator in the use of the data collection instrument. Kappa, a measure of agreement, was performed to measure interrater reliability. There was a substantial level of agreement on the individual components of the discharge planning process (i.e., probed, identified, planned, and followed through). The measures of inter-rater reliability for the rounds in the baseline sample, intervention time 1 sample, and intervention time 2 sample were kappa = .82, .80, and .70, respectively. Landis and Koch (1977) defined the degree of agreement strength as substantial (.61 to .80) and almost perfect (.81 to 1.00). Thus, the interrater reliability for the rounds was substantiated. RESULTS AND DISCUSSION There were no significant differences in the sociodemographic characteristics of age, gender, race, and the social support indicators for the study sample for each time period. This further established the comparability of the hospital sides. Total percentages of these variables for all time periods are shown in Table 1. The social support indicators, "lived alone" and " n o one to help after discharge," could have implications for assistance or use of community resources after hospitalization. At baseline, 3.38 needs (SD = 2.06) were the average number of needs discussed (i.e., probed, identified, planned for, or followed through on) in the rounds on side one compared with 3.45 needs (SD = 2.25) on side 2; 3.19 needs (SD = 2.44) discussed at rounds by the experimental group compared with 3.48 needs (SD = 2.25) discussed
Table 1. Total Percentage Comparisons of Sociodemographics and Social Support Indicators for Baseline, Time 1, and Time 2 Sociodernographies and Social Support Indicators Age (years) Under 45 45-64 65 & older Gender Male Female Race White All other Marital status Married Unmarried Living arrangements House/apartment with others Lived alone Apartment senior building Community facility Social support Spouse and/or children Other relations, friends Agencies No one
Baseline Time 1 Time 2 (5 weeks; (9 weeks; (9 weeks; N = 139) N = 246) N = 260) 5.7 40.2 53.9
7.7 37.3 54.8
10.0 34.0 56.0
38.1 61.8
38.6 61.3
40.4 59.6
14.4 85.5
16.1 83.8
13.9 86.0
44.9 55.0
41.8 58.1
44.0 56.0
74.8 20.4 2.3 2.3
73.7 21.9 1.7 2.5
71.8 24.8 1.6 1.6
61.4 25.9 5.5 7.0
58.2 27.0 8.5 6.1
63.7 25.3 4.2 6.7
Social support was defined as " w h o is available to help after discharge." All values ere expressed as percentage.
by the control group at time 1; and 2.98 needs (SD = 2.04) discussed at rounds by the experimental group compared with 3.35 needs (SD = 2.12) by the control group at time 2. The differences between the groups in baseline or in each of the two intervention time periods were neither statistically nor clinically significant: baseline, t(137) = .211, p = .83; time 1, t(244) = 1.06,p = .29; and time 2, t(248) = 1.395, p = . 16. During all time periods, only a small percentage of the possible needs as based on the 12 need categories were discussed at rounds. Health education needs and personal care needs were most frequently discussed (Table 2). The investigator expected that a range of continuing care needs, as listed on the data collection tool, would be discussed in the rounds. This was not the case as can be seen by reviewing Table 2. Transportation was rarely discussed and yet this need area could have major implications for patients being able to keep followup appointments for ongoing care. With an interdisciplinary team in both rounds groups, it is sur-
ACUTE CARE DISCHARGE PLANNING ROUNDS
71
Table 2. Percentage Comparison of Need Areas Discussed in Rounds by Multidisciplinary Groups Varying in Size and Composition, Experimental and Control, Times 1 and 2 Time 1
Time 2
Need Areas Discussed
Experimental (Side 1; N = 118)
Control (Side 2; N = 128)
Experimental (Side 2; N = 1171
Control (Side 1; N =133)
Housing Finances Community nursing Health education Psychosocial Nutritional Personal care Care of environment Equipment]supplies Rehabilitation Transportation Medical care
.8 1.3 2.8 38.1 4.9 .4 15.9 5.5 4.4 3.9 .4 1.3
1.4 .9 4.9 40.2 6.4 2.3 19.1 3.5 2.9 3.5 .2 1.2
1.7 1.7 3.2 31.8 4.3 1.5 22.4 3.0 1.5 2.1 .4 .4
1.9 1.1 3.3 40.4 6.4 1.7 19.0 4.0 1.7 2.3 .4 1.3
Discussed = probed, identified, planned, or followed through on need area. Experimental = three providers: registered nurse on the unit, social worker assigned to the unit, and the discharge planning nurse coordinator. Control = six providers: registered nurse on the unit, social worker assigned to the unit, discharge planning nurse coordinator, health promotion coordinator, dietician, and pastoral care representative. All values denote percentage.
prising that the needs discussed were so narrowly focused. As Hartigan (1987) stated, "There is no single, universally applicable formula for determining which patients will benefit most from discharge planning . . . . assessment of discharge needs is required" (p. 31). Indeed, in looking at the components of the discharge planning process as defined in this study, the findings suggest that the control group (six providers) probed and identified more needs at the rounds than the experimental group (three providers). Using a two-way analysis of variance with repeated measures (2 groups x 2 times) for the rounds, there was a trend toward a treatment difference with the control group probing more than the experimental group. However, this was not statistically significant F(1,492) = 3.09, p = .08. Mean number of needs probed ranged from 1.34 needs (SD = 1.11) for the controls to 1.08 needs (SD = 1.04) for the experimentals at time 1 and 1.17 needs (SD = 1.00) for the controls to 1.10 needs (SD = 1.02) for the experimentals at time 2. This means that on average, out of the possible 12 need areas only one need area was probed for each patient in this study. There was a statistically significant treatment difference with the control group (M = 1.56 needs, SD = .99) identifying more needs in the rounds than the experimental group (M = 1.23 needs, SD = .96), F(1,492) = 5.01, p = .03.
Although this is statistically significant, the clinical significance is questionable. The difference between the two groups is less than half a need identified. Interestingly the control group probed more but followed through less than the experimental group. This may be because of greater dispersion of responsibility and accountability with six providers (control group) in the rounds. Casefinding, which is identifying patients who need discharge planning, may occur at the rounds. However, planning during the rounds to meet the identified needs was consistently low. The mean number of needs planned for was .53 needs (SD = .76) control group and .43 needs (SD = .66) experimental group at time 1, and .34 needs (SD = .53) control and .41 needs (SD = .60) experimental at time 2. This translates to planning for less than one-half need per patient as measured by the 12 needs in this study. Findings suggest that the experimental group (three providers) was as effective as the control group (six providers) based on the mean number of need areas discussed in each time period as previously reported. However, the average number of needs discussed in the discharge planning rounds was only 3 out of a possible 12 needs. Discussed did not mean that the entire process had been performed. Nursing was represented in both of these groups. In the experimental group (three providers), there was the nurse on the unit and the discharge planning nurse
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PATRICIA A. O'HARE
coordinator. In the control group (six providers), nursing was represented by the nurse on the unit, the discharge planning nurse coordinator, and the health promotion coordinator. IMPLICATIONS FOR NURSING
Also at issue is whether or not nurses are prepared to function in the rounds as members o f interdisciplinary teams. This interdisciplinary team functioning would include the role negotiation and conflict resolution skills that are part of the group process. Addressing the issues of what other skills are necessary and how to develop these skills in interdisciplinary team situations, such as the rounds, are critical. Nurses were positioned to play a prominent role in these discharge planning rounds. However, from data collected in this study, the investigators found that staff nurses were uncertain of their role in the rounds. Reichelt and N e w c o m b (1980) found evidence in the literature and in personal contacts that staff nurses were uncertain about how to do discharge planning. In a random sample of 50 pairs of elderly clients and their patients on two medical units in an acute care hospital, Johnson (1989) found a lack of agreement between the nurses and their patients on which discharge needs were most important. The staff nurses' uncertainty regarding their roles in discharge planning and lack of agreement between patient and nurse regarding discharge needs has major implications for education and practice. Staff development programs are necessary regarding the discharge planning process and the staff nurses' role in that process especially as it concerns discharge planning rounds. These education programs would include discussion of continuing care needs based on the 12 need areas addressed in this study. These needs include not only teaching and referrals regarding the high-tech procedure(s) but also an assessment of the patient's psychosocial situation, availability and ability of a caregiver, insurance coverage, resources in the community, and other aspects of ongoing care. Case studies and role play are two educational strategies used to explore patient care needs beyond acute care. The use of a form such as the data collection tool used in this study would provide a systematic way of recording needs discussed. Such a form would also serve as a cue to possible needs for all providers participating in the rounds. Discharge planning is concerned with two issues
in health care delivery; quality o f care and the cost of providing that care efficiently and effectively. Rounds are one o f the mechanisms used in hospital discharge planning models as part of the process for efficient and effective discharge planning. The results of this study suggest that greater emphasis should be placed on understanding the rounds, the roles of participants in the rounds, and the effects of the rounds on patient care services for continuity of care. In the interest of total quality management and cost-effective care, further evaluations o f the process and o u t c o m e s o f discharge planning rounds are essential. REFERENCES Anderson, G.F., & Steinberg, E.P. (1985). Predicting hospital readmissions in the Medicare population. Inquiry, 22(3), 251-258. Arenth, L.M., & Mamon, J.A. (1985). Determiningpatient needs after discharge. Nursing Management, 16(9), 20-24. Bristow, O., Stickney, C., & Thompson, S. (1976). Discharge Planning for Continuity of Care. New York, NY: National League for Nursing. Chakrabarty, C., Beallor, G.N., & Pelle, D. (1988). A multidisciplinary approach to continuing care planning. In P.J. Volland (Ed.), Discharge planning an interdisciplinary approach to contin,dty of care. Owing Mills, MD: National Health Publishing. Discharge Planning Models: The Long Island College Hospital, Brooklyn, NY: (1983). Discharge Planning Update, 3(4), 24-30. Donabedian, A. (1978). Needed research on the assessment and monitoring of the quality of medical care. Hyattsville, MD: Department of Health, Education and Welfare, Public Health Service. Donabedian, A., & Rosenfeld, L. (1964). Follow-up study of chronically ill patients discharged from hospital. Journal of Chronic Diseases, 17, 847-862. Edwards, R.C. (1978). Professionals in 'Alliance' achieve more effective discharge planning. Hospitals, 12, 71-72. Fethke, C.C., Smith, I.M., & Johnson, N. (1986). "Risk" factors affecting readmission of the elderly into the health care system. Medical Care, 24(5), 429-437. Fortune, M. (1981) The role of the community health nursing consultant in discharge planning. Unpublished report, University of Rochester School of Nursing. Rochester, NY. Gooding, J., & Jette, A.M. (1985). Hospital readmissions among the elderly. Journal of the American Geriatric Society, 33, 595-601. Hartigan, E.G. (1987). Discharge planning: Identificationof high-risk groups. Nursing Management, 18(2), 30-32. Holloway, J.J., Thomas, J.W., & Shapiro, L. (1988). Clinical and sociodemographicrisk factors for readmission of Medicare beneficiaries. Health Care Financing Review, 10(1), 2736. Johnson, J. (1989). Where's discharge planning on your list? Geriatric Nursing, 10, 148-149. Kark, E., & Hopp, C. (1970). A follow-up study of patients
ACUTE CARE DISCHARGE PLANNING ROUNDS
discharged from a Jerusalem hospital. Medical Care, 8(6), 510522. Kerstein, M.D., Baker, R.C., & Maguire, M.K. (1985). Do not ignore the physician in discharge planning. In E.G. Hartigan & D.J. Brown (Eds.), Discharge planning for continuity of care (rev. ed. pp. 79-82). New York, NY" National League for Nursing. LaMontagne, M.E., & McKeehan, K.M. (1975). Profile of a continuing care program emphasizing discharge planning. Journal of Nursing Administration, 5(8), 22-33. Landis, J.R., & Koch, G.G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33, 159174. Lindenberg, R.E., & Coulton, C. (1980). Planning for posthospital care: A follow-up study. Health and Social Work, 5, 45-50. Morgan, D. (1973). Discharge planning: An asset in the continuum of patient care services. Canadian Hospital, 50(9), 28-30, 47. Nash, T.B. (1988). What's new about the new discharge
73 planning standards? Discharge Planning Update, 8(5), 1, 1113. Omnibus Budget Reconciliation Act (OBRA) of 1986, Conference Report to Accompany H.R.5300. Section 9305. Washington, DC. Previte, V.J. (1979). Continuing care in a primary nursing setting: Role of a clinical specialist. International Nursing Review, 26(2), 53-56. Reichelt, P.A., & Newcomb, J. (1980). Organizational factors in discharge planning. Journal of Nursing Administration, 10, 36-42. Steiner, I.D. (1972). Group Process and Productivity. New York, NY: Academic Press. Willard, H., & Kasl, S.V. (1972). Continuing Care in a Community Hospital. Cambridge, England: Harvard University Press. Zook, C.J., Saviciis, S.F., & Moore, F.D. (1980). Repeated hospitalizations for the same disease: A multiplier of national health costs. Milbank Memorial Fund Quarterly, 58, 454-470.
Rounds are a primary part of the discharge planning process in acute care hospitals. The multidisciplinary aspect of rounds has been accepted as a given, but the differences resulting from differently composed interdisciplinary groups functioning in rounds has not been investigated. This experimental study examined two models of discharge planning rounds and compared their effects on the process of probing, identifying, planning for, and following through on patient discharge needs. Copyright © 1992 by W.B. Saunders Company
ISCHARGE PLANNING has taken on new importance for both professionals and consumers in today's fiscally constrained health care environment. In the acute care setting, the inclusion of the discharge planning process as a Medicare "condition of participation" has been mandated by legislation and subsequent regulations (Omnibus Budget Reconciliation Act, 1986). The Joint Commission on Accreditation of Healthcare Organizations in their 1989 Accreditation Manual for Hospitals included standards that require a hospital to establish a formal discharge planning process (Nash, 1988). Discharge planning rounds are a case-finding, coordination, and communication mechanism in the discharge planning process; various health care providers meet on a regularly scheduled basis, usually weekly, to review the current status of all patients on a particular unit (Discharge Planning Models, 1983; Kerstein, Baker, & Maguire, 1985). It is specifically through the rounds that provider interaction can occur on a scheduled basis, with planning carried out in a timely manner based on the patient's condition and
D
From the School of Nursing, Georgetown University, Washington, DC. Patricia A. O'Hare, DrPH, hiS, RN: Assistant Professor of Nursing, Georgetown University School of Nursing, Washington, DC, and currently a Postdoctoral Fellow in Psychosocial Oncology, Unh'ersity of Pennsyh'ania School of Nursing, Philadelphia, PA. This research was supported by a Predoctoral National Research Service Award (NRSA) Nurse Fellowship from the DHHS, PHS, HRSA, #SF-31-NU-05398-15. Address reprint requests to Patricia A. O'Hare, DrPH, MS, RN, 13026 Victoria Heights Dr, Bowie, MD 20715. Copyright © 1992 by W.B. Saunders Company 0897-1897/92/0502-001055.00/0
66
identified needs. Routine rounds provide an opportunity for early and continuous assessment, adequate planning, and referral. These rounds also provide the occasion for determining and documenting which patients do not require discharge planning assistance. The size and composition of the rounds team are structural features worthy of study. The size and composition of the rounds team may affect identification of needs, receipt of services, and overall use of hospital services. No evaluative research of discharge planning team rounds, either process or composition, has appeared in the literature. Therefore, this experimental study tested two models of discharge planning rounds in an acute care community teaching hospital and compared their effects on the process of probing, identifying, planning for, and following through on patient discharge needs. BACKGROUND
Bristow, Stickney, and Thompson (1976) have written that regular discharge conferences should be held on each unit with the "full range" of professionals represented. Chakrabarty, Beallor, and Pelle (1988) state that, "Generally, the continuing care planning team will consist of representatives from social services, nursing, medicine, nutrition, physical therapy, occupational therapy, speech therapy, and home care. The composition of the team may vary depending on the intensity of services required in moving the patient from one level of care to another" (p. 154). Interdisciplinary discharge planning team meetings are the formal structure described in the literature but the "empirical evidence concerning the effect of group size Applied Nursing Research, Vol. 5, No. 2 (May), 1992: pp. 66-73
67
ACUTE CARE DISCHARGE PLANNING ROUNDS
on actual productivity is highly fragmented and incomplete" (Steiner, 1972, p. 89). Various models of the size and composition of the rounds team have been described in the literature ranging from one or two providers (Morgan, 1973; Previte, 1979; Reichelt & Newcomb, 1980) to a multidisciplinary team. This multidisciplinary team could be composed of the physician (resident oi" attending), head nurse on the unit, other nursing staff, social worker, dietician, physical therapist, pharmacist, community health nursing consultant, utilization review coordinator, home care department representative, pastoral care department representative, and possibly other professionals (Arenth & Mamon, 1985; Chakrabarty et al., 1988; Edwards, 1978; Fortune, 1981; LeMontagne & McKeehan, 1975; Willard & Kasl, 1972). An important issue is what effect, if any, does the size and composition of the rounds team have on identifying, assessing, and planning for resources to meet a patient's continuing care needs at discharge. As Steiner (1972) noted, " . . . if a group is already large enough to possess all the relevant resources needed to perform a task well, the addition of new members may cause process losses without adding anything whatever to potential productivity" (p. 82). Donabedian's (1978) conceptual framework of structure, process, outcome was used for this study. It was postulated that structural characteristics of the health care delivery system, namely the size
A basic group of three providers (experimental group) participating in rounds were compared with a larger group of six providers (control group).
charge planning was defined by the number of needs probed, identified, planned for, and followed through on in the rounds. The greater the number of needs discussed, the more effective the discharge planning. METHODS
An experimental crossover design was used to test two models of discharge planning in an acute care community teaching hospital. With the crossover design, both the intervention and the control or usual treatment were able to be measured on both sides of the hospital during the time of the study. Each hospital side therefore acted as its own control in terms of confounding factors such as unit staff differences. A basic group of three providers (experimental group) participating in rounds were compared with a larger group of six providers (control group). The three-provider model (experimental) consisted of the nurse on the unit, the social worker assigned to the unit, and the discharge planning nurse coordinator. The six provider model (control) consisted of the nurse on the unit, social worker assigned to the unit, discharge planning nurse coordinator, health promotion coordinator, dietician, and a pastoral care department representative. In this study, the health promotion coordinator was a registered nurse with a master's degree in nursing and 5 years of clinical experience including patient and staff education. The discharge planning nurse coordinator was baccalaureate prepared and had practiced in home health. The social workers had master's degrees. The registered nurses on the units were educationally prepared at the diploma or associate degree levels; a few were baccalaureate nursing graduates. The dieticians were registered dieticians. The representatives from the pastoral care department were all members of religious orders with varying backgrounds and preparation. PROCEDURE
and composition of the group for the discharge planning rounds, would effect the discharge planning process. Ultimately, the process effects the outcomes, such as teaching and referrals, to meet those discharge needs. Thus, the purposes of this study were to determine which professionals and how many providers need to be involved in rounds for effective discharge planning. Effective dis-
The study had three phases. These phases were baseline (pre-experimental) and two intervention periods. Two sides of a 355-bed community teaching hospital were used for the study. Each side included a medical, surgical, and medical/surgical unit; the two sides of the hospital were functionally separate. Equivalency of the two sides were tested at baseline and in both intervention periods; the
PATRICIA A. O'HARE
68
sides were found to be similar. Thus, there was no selectivity in terms of the kinds of patients admitted to one side or the other from acuity or reimbursement perspectives. The intervention was the use of a three-provider group in the rounds. Randomization was by hospital side. The crossover design was used to allow both sides of the hospital to be exposed to the intervention. In other words, the side of the hospital that was randomly assigned as the experimental group during intervention period one became the control group during intervention period two and vice versa. During the pre-experimental baseline period, the discharge planning rounds were conducted in the usual way with the six providers. The pre-experimental period was 5 weeks and data were collected on 139 patients. Data were collected on 246 patients during intervention time one and on 260 patients during intervention time two. Each intervention phase was 9 weeks with a recovery period of 8 weeks separating the two intervention phases. The recovery period was to decrease the crossover effect from the previous time period. The study was performed at weekly interdisciplinary continuity of care rounds on two sides of the hospital. Patients were included in the sample if they (a) were discussed at rounds at least one time; (b) had a hospital length of stay of 5 to 31
Effectiveness of the discharge planning rounds was measured by the number of patient discharge needs probed, identified, planned for, and followed through on in the rounds process. days; and (c) were in one of six broad diagnostic categories. The diagnostic categories included cancer, diabetes, diseases of the blood vessels, heart, respiratory system, and chronic renal failure. Selection of the diagnostic categories was based on the rationale that these diagnosis-related groups were likely to have more need for discharge planning due to the recuperative period or chronicity of the disease (Anderson & Steinberg, 1985; Donabedian & Rosenfeld, 1964; Fethke, Smith, &
Johnson, 1986; Gooding & Jette, 1985; Holloway, Thomas, & Shapiro, 1988; Kark & Hopp, 1970; Lindenberg & Coulton, 1980; Zook, 1980). INSTRUMENT
Effectiveness of the discharge planning rounds was measured by the number of patient discharge needs probed, identified, planned for, and followed through on in the rounds process. The data collection methods were observation and tape recording of the rounds and a chart audit after the patient was discharged. A structured instrument (Figure 1) was used to measure the process. The operational definitions of the process were as follows: 1. Probed. The providers participating in the rounds asked questions regarding the particular need to determine if the need was present or not. 2. Identified. The determination by one or more providers that such a need was present. 3. Planned. The decision, by the providers participating in the rounds, as to how an identified or potentially identified need would be met. 4. Followed through. The fact that the need was met. This completed the process and included statements at rounds that a task to meet a need had been performed. It was also expected that outcomes would be documented in the patient's chart. For example, the outcomes documented were that referrals to other disciplines or agencies had been made, literature had been distributed, and/or classes has been attended. A separate data collection form was used for each patient discussed who met the criteria for inclusion in the study. The unit of analysis was patient needs. The instrument was scored by summing the individual need categories so that a measurement of the total number of needs that were probed, identified, planned for, and followed through on was obtained. These numbers were so small that it was decided to include a need as discussed even if only one part of the process from probing to following through was achieved. If the patients included in the study were discussed at rounds more than one time, a new data collection form was used for each week. The data were then combined for all rounds for each study patient at the time of coding and data entry into the computer file. A separate data collection form was used for each patient to record the discharge planning pro-
Unit: Housing and Social Sit.
Study No.
Date of Rounds Diagnoses.
NEEDS ASSESSMENT TOOL FOR RECORDING CONTENT OF ROUNDS AND MEDICAL RECORD Need Areas Disch. Date Disc?
Probed by whom
Identified by whom
Planned by whom
Followed Through On Met by How whom
HOUSING FINANCES NURSING CARE ° Community Nursing 1. 2. 3. 4.
Skilled/Care/Procedures Follow-Up Teaching Follow-Up Supervision Other
HEALTH EDUCATION 1. 2. 3. 4. 5.
Knows Diagnosis Understands Diagnosis Will Attend Classes Will Receive 1-1 Teaching Family/SO Will Attend 6. Family/SO 1-1 Teaching 7. Other PSYCHOSOCIAL PROBLEMS ASSOC. WITH ILLNESS/DISABILITY 1, Counseling (Pt/Family) 2. Ref. to Self-Help Grp (PtJF) 3. Ref. to Supportive Vol (PtJF) 4. Other NUTRITIONAL 1. Arrange Meals on Wheels 2. Homemaker Prepare Meals 3, Food Stamps 4. Other ASSISTANCE WITH PERSONAL CARE ASST. WITH CARE OF ENVIRONMENT EQUIPMENT/SUPPLIES REHABILITATION: PT; OT; SPEECH TRANSPORTATION MEDICAL CARE TOTAL
Figure 1. Data collection tool. From Examining the Discharge Planning Process: An Evaluation of Two Models in an Acute Care Community Hospital, (Doctoral Dissertation, The Johns Hopkins University}. Copyright © 1984 by Patricia A. O'Hare.
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70
cess as documented in the chart. Chart documentation of the process as compared with the rounds process is discussed in another manuscript in preparation. The structured instrument consisted of 12 need categories (Figure 1). These categories were determined from the literature (Lindenberg & Coulton, 1980) and the knowledge and experience of the investigator. Nurses and social workers also reviewed the instrument before and after the data collection for clarity and consistency with categories represented in the literature. This structured data collection instrument has face validity and content validity. All the data for the study were collected by the investigator. Fifteen percent of the data were reviewed by an independent reviewer for inter-rater reliability. This independent reviewer was a master's student in medical-surgical nursing who was trained by the investigator in the use of the data collection instrument. Kappa, a measure of agreement, was performed to measure interrater reliability. There was a substantial level of agreement on the individual components of the discharge planning process (i.e., probed, identified, planned, and followed through). The measures of inter-rater reliability for the rounds in the baseline sample, intervention time 1 sample, and intervention time 2 sample were kappa = .82, .80, and .70, respectively. Landis and Koch (1977) defined the degree of agreement strength as substantial (.61 to .80) and almost perfect (.81 to 1.00). Thus, the interrater reliability for the rounds was substantiated. RESULTS AND DISCUSSION There were no significant differences in the sociodemographic characteristics of age, gender, race, and the social support indicators for the study sample for each time period. This further established the comparability of the hospital sides. Total percentages of these variables for all time periods are shown in Table 1. The social support indicators, "lived alone" and " n o one to help after discharge," could have implications for assistance or use of community resources after hospitalization. At baseline, 3.38 needs (SD = 2.06) were the average number of needs discussed (i.e., probed, identified, planned for, or followed through on) in the rounds on side one compared with 3.45 needs (SD = 2.25) on side 2; 3.19 needs (SD = 2.44) discussed at rounds by the experimental group compared with 3.48 needs (SD = 2.25) discussed
Table 1. Total Percentage Comparisons of Sociodemographics and Social Support Indicators for Baseline, Time 1, and Time 2 Sociodernographies and Social Support Indicators Age (years) Under 45 45-64 65 & older Gender Male Female Race White All other Marital status Married Unmarried Living arrangements House/apartment with others Lived alone Apartment senior building Community facility Social support Spouse and/or children Other relations, friends Agencies No one
Baseline Time 1 Time 2 (5 weeks; (9 weeks; (9 weeks; N = 139) N = 246) N = 260) 5.7 40.2 53.9
7.7 37.3 54.8
10.0 34.0 56.0
38.1 61.8
38.6 61.3
40.4 59.6
14.4 85.5
16.1 83.8
13.9 86.0
44.9 55.0
41.8 58.1
44.0 56.0
74.8 20.4 2.3 2.3
73.7 21.9 1.7 2.5
71.8 24.8 1.6 1.6
61.4 25.9 5.5 7.0
58.2 27.0 8.5 6.1
63.7 25.3 4.2 6.7
Social support was defined as " w h o is available to help after discharge." All values ere expressed as percentage.
by the control group at time 1; and 2.98 needs (SD = 2.04) discussed at rounds by the experimental group compared with 3.35 needs (SD = 2.12) by the control group at time 2. The differences between the groups in baseline or in each of the two intervention time periods were neither statistically nor clinically significant: baseline, t(137) = .211, p = .83; time 1, t(244) = 1.06,p = .29; and time 2, t(248) = 1.395, p = . 16. During all time periods, only a small percentage of the possible needs as based on the 12 need categories were discussed at rounds. Health education needs and personal care needs were most frequently discussed (Table 2). The investigator expected that a range of continuing care needs, as listed on the data collection tool, would be discussed in the rounds. This was not the case as can be seen by reviewing Table 2. Transportation was rarely discussed and yet this need area could have major implications for patients being able to keep followup appointments for ongoing care. With an interdisciplinary team in both rounds groups, it is sur-
ACUTE CARE DISCHARGE PLANNING ROUNDS
71
Table 2. Percentage Comparison of Need Areas Discussed in Rounds by Multidisciplinary Groups Varying in Size and Composition, Experimental and Control, Times 1 and 2 Time 1
Time 2
Need Areas Discussed
Experimental (Side 1; N = 118)
Control (Side 2; N = 128)
Experimental (Side 2; N = 1171
Control (Side 1; N =133)
Housing Finances Community nursing Health education Psychosocial Nutritional Personal care Care of environment Equipment]supplies Rehabilitation Transportation Medical care
.8 1.3 2.8 38.1 4.9 .4 15.9 5.5 4.4 3.9 .4 1.3
1.4 .9 4.9 40.2 6.4 2.3 19.1 3.5 2.9 3.5 .2 1.2
1.7 1.7 3.2 31.8 4.3 1.5 22.4 3.0 1.5 2.1 .4 .4
1.9 1.1 3.3 40.4 6.4 1.7 19.0 4.0 1.7 2.3 .4 1.3
Discussed = probed, identified, planned, or followed through on need area. Experimental = three providers: registered nurse on the unit, social worker assigned to the unit, and the discharge planning nurse coordinator. Control = six providers: registered nurse on the unit, social worker assigned to the unit, discharge planning nurse coordinator, health promotion coordinator, dietician, and pastoral care representative. All values denote percentage.
prising that the needs discussed were so narrowly focused. As Hartigan (1987) stated, "There is no single, universally applicable formula for determining which patients will benefit most from discharge planning . . . . assessment of discharge needs is required" (p. 31). Indeed, in looking at the components of the discharge planning process as defined in this study, the findings suggest that the control group (six providers) probed and identified more needs at the rounds than the experimental group (three providers). Using a two-way analysis of variance with repeated measures (2 groups x 2 times) for the rounds, there was a trend toward a treatment difference with the control group probing more than the experimental group. However, this was not statistically significant F(1,492) = 3.09, p = .08. Mean number of needs probed ranged from 1.34 needs (SD = 1.11) for the controls to 1.08 needs (SD = 1.04) for the experimentals at time 1 and 1.17 needs (SD = 1.00) for the controls to 1.10 needs (SD = 1.02) for the experimentals at time 2. This means that on average, out of the possible 12 need areas only one need area was probed for each patient in this study. There was a statistically significant treatment difference with the control group (M = 1.56 needs, SD = .99) identifying more needs in the rounds than the experimental group (M = 1.23 needs, SD = .96), F(1,492) = 5.01, p = .03.
Although this is statistically significant, the clinical significance is questionable. The difference between the two groups is less than half a need identified. Interestingly the control group probed more but followed through less than the experimental group. This may be because of greater dispersion of responsibility and accountability with six providers (control group) in the rounds. Casefinding, which is identifying patients who need discharge planning, may occur at the rounds. However, planning during the rounds to meet the identified needs was consistently low. The mean number of needs planned for was .53 needs (SD = .76) control group and .43 needs (SD = .66) experimental group at time 1, and .34 needs (SD = .53) control and .41 needs (SD = .60) experimental at time 2. This translates to planning for less than one-half need per patient as measured by the 12 needs in this study. Findings suggest that the experimental group (three providers) was as effective as the control group (six providers) based on the mean number of need areas discussed in each time period as previously reported. However, the average number of needs discussed in the discharge planning rounds was only 3 out of a possible 12 needs. Discussed did not mean that the entire process had been performed. Nursing was represented in both of these groups. In the experimental group (three providers), there was the nurse on the unit and the discharge planning nurse
72
PATRICIA A. O'HARE
coordinator. In the control group (six providers), nursing was represented by the nurse on the unit, the discharge planning nurse coordinator, and the health promotion coordinator. IMPLICATIONS FOR NURSING
Also at issue is whether or not nurses are prepared to function in the rounds as members o f interdisciplinary teams. This interdisciplinary team functioning would include the role negotiation and conflict resolution skills that are part of the group process. Addressing the issues of what other skills are necessary and how to develop these skills in interdisciplinary team situations, such as the rounds, are critical. Nurses were positioned to play a prominent role in these discharge planning rounds. However, from data collected in this study, the investigators found that staff nurses were uncertain of their role in the rounds. Reichelt and N e w c o m b (1980) found evidence in the literature and in personal contacts that staff nurses were uncertain about how to do discharge planning. In a random sample of 50 pairs of elderly clients and their patients on two medical units in an acute care hospital, Johnson (1989) found a lack of agreement between the nurses and their patients on which discharge needs were most important. The staff nurses' uncertainty regarding their roles in discharge planning and lack of agreement between patient and nurse regarding discharge needs has major implications for education and practice. Staff development programs are necessary regarding the discharge planning process and the staff nurses' role in that process especially as it concerns discharge planning rounds. These education programs would include discussion of continuing care needs based on the 12 need areas addressed in this study. These needs include not only teaching and referrals regarding the high-tech procedure(s) but also an assessment of the patient's psychosocial situation, availability and ability of a caregiver, insurance coverage, resources in the community, and other aspects of ongoing care. Case studies and role play are two educational strategies used to explore patient care needs beyond acute care. The use of a form such as the data collection tool used in this study would provide a systematic way of recording needs discussed. Such a form would also serve as a cue to possible needs for all providers participating in the rounds. Discharge planning is concerned with two issues
in health care delivery; quality o f care and the cost of providing that care efficiently and effectively. Rounds are one o f the mechanisms used in hospital discharge planning models as part of the process for efficient and effective discharge planning. The results of this study suggest that greater emphasis should be placed on understanding the rounds, the roles of participants in the rounds, and the effects of the rounds on patient care services for continuity of care. In the interest of total quality management and cost-effective care, further evaluations o f the process and o u t c o m e s o f discharge planning rounds are essential. REFERENCES Anderson, G.F., & Steinberg, E.P. (1985). Predicting hospital readmissions in the Medicare population. Inquiry, 22(3), 251-258. Arenth, L.M., & Mamon, J.A. (1985). Determiningpatient needs after discharge. Nursing Management, 16(9), 20-24. Bristow, O., Stickney, C., & Thompson, S. (1976). Discharge Planning for Continuity of Care. New York, NY: National League for Nursing. Chakrabarty, C., Beallor, G.N., & Pelle, D. (1988). A multidisciplinary approach to continuing care planning. In P.J. Volland (Ed.), Discharge planning an interdisciplinary approach to contin,dty of care. Owing Mills, MD: National Health Publishing. Discharge Planning Models: The Long Island College Hospital, Brooklyn, NY: (1983). Discharge Planning Update, 3(4), 24-30. Donabedian, A. (1978). Needed research on the assessment and monitoring of the quality of medical care. Hyattsville, MD: Department of Health, Education and Welfare, Public Health Service. Donabedian, A., & Rosenfeld, L. (1964). Follow-up study of chronically ill patients discharged from hospital. Journal of Chronic Diseases, 17, 847-862. Edwards, R.C. (1978). Professionals in 'Alliance' achieve more effective discharge planning. Hospitals, 12, 71-72. Fethke, C.C., Smith, I.M., & Johnson, N. (1986). "Risk" factors affecting readmission of the elderly into the health care system. Medical Care, 24(5), 429-437. Fortune, M. (1981) The role of the community health nursing consultant in discharge planning. Unpublished report, University of Rochester School of Nursing. Rochester, NY. Gooding, J., & Jette, A.M. (1985). Hospital readmissions among the elderly. Journal of the American Geriatric Society, 33, 595-601. Hartigan, E.G. (1987). Discharge planning: Identificationof high-risk groups. Nursing Management, 18(2), 30-32. Holloway, J.J., Thomas, J.W., & Shapiro, L. (1988). Clinical and sociodemographicrisk factors for readmission of Medicare beneficiaries. Health Care Financing Review, 10(1), 2736. Johnson, J. (1989). Where's discharge planning on your list? Geriatric Nursing, 10, 148-149. Kark, E., & Hopp, C. (1970). A follow-up study of patients
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discharged from a Jerusalem hospital. Medical Care, 8(6), 510522. Kerstein, M.D., Baker, R.C., & Maguire, M.K. (1985). Do not ignore the physician in discharge planning. In E.G. Hartigan & D.J. Brown (Eds.), Discharge planning for continuity of care (rev. ed. pp. 79-82). New York, NY" National League for Nursing. LaMontagne, M.E., & McKeehan, K.M. (1975). Profile of a continuing care program emphasizing discharge planning. Journal of Nursing Administration, 5(8), 22-33. Landis, J.R., & Koch, G.G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33, 159174. Lindenberg, R.E., & Coulton, C. (1980). Planning for posthospital care: A follow-up study. Health and Social Work, 5, 45-50. Morgan, D. (1973). Discharge planning: An asset in the continuum of patient care services. Canadian Hospital, 50(9), 28-30, 47. Nash, T.B. (1988). What's new about the new discharge
73 planning standards? Discharge Planning Update, 8(5), 1, 1113. Omnibus Budget Reconciliation Act (OBRA) of 1986, Conference Report to Accompany H.R.5300. Section 9305. Washington, DC. Previte, V.J. (1979). Continuing care in a primary nursing setting: Role of a clinical specialist. International Nursing Review, 26(2), 53-56. Reichelt, P.A., & Newcomb, J. (1980). Organizational factors in discharge planning. Journal of Nursing Administration, 10, 36-42. Steiner, I.D. (1972). Group Process and Productivity. New York, NY: Academic Press. Willard, H., & Kasl, S.V. (1972). Continuing Care in a Community Hospital. Cambridge, England: Harvard University Press. Zook, C.J., Saviciis, S.F., & Moore, F.D. (1980). Repeated hospitalizations for the same disease: A multiplier of national health costs. Milbank Memorial Fund Quarterly, 58, 454-470.
