Comprehensive discharge planning for the elderly.

Research in Nursing & Health, 1990, 13,327-347

Special Feature An Example of a Research Grant Application Comprehensive Discharge Planning for the Elderly Mary D. Naylor

EDITOR’S NOTE Earlier this year I was asked by Dr. Ada Sue Hinshaw, Director of the National Center for Nursing Research, National Institutes of Health (NCNR, NIH), if we would consider publishing in Research in Nursing & Health a research grant application and its subsequent evaluation by the Nursing Research Study Section. Dr. Hinshaw related that numerous requests are received at NCNR for copies of such applications and the accompanying summary statements. As noted in her editorial in this issue of the journal, the Center can respond only to requests for copies of funded proposals and, even then, cannot share the critiques. The need for persons to see actual examples of the elements that go into a successful grant application and the type of critique the application receives appeared considerable, however. The publication of such material, upon consent of the principal investigator, is an accessible medium that was seen to be a helpful service, especially to new investigators. I am pleased that we can provide this professional service through the journal. Publication of this particular application does not imply that it is the preferred type of application at NCNR, nor does it imply endorsement by this journal of a preferred research approach. The choice was made on the basis that it be a recent individual investigator (R01) application, that it receive a priority score within the funding range, and that it would be of interest to a fairly wide range of researchers. The

present application received a priority score of 11 1. Readers will note that the Study Section’s comments are almost entirely positive, as would be expected given their assignment of the high priority rating. The focus of the comments will indicate, however, the elements of an application that are evaluated and implicit criteria can be inferred from the statements. We are indebted to Dr. Mary D. Naylor, the principal investigator, for her willingness to share her work in this form. All of the narrative portion of the application, with the exception of a few sentences, is included and only minor editing has been done. The section on budget and budget justification and the several appendices are not included. These exclusions should not hamper an understanding of the proposal.

Project Personnel The principal investigator, Mary D. Naylor, PhD, RN, is an assistant professor in the School of Nursing, University of Pennsylvania. The five coinvestigators, all at the University of Pennsylvania, are Dorothy Brooten, PhD, RN, and Mathy Mezey, EdD, RN, professors in the School of Nursing; Robert Jones, PhD, an associate professor in the Wharton School; Risa Lavizzo-Mourey, MD, MBA, an assistant professor in the School of Medicine; and Mark Pauly, PhD, a professor in the Wharton School and the executive director of the Leonard Davis Institute.

Requests for reprints can be addressed to Dr. Mary D. Naylor, School of Nursing, University of Pennsylvania, 420 Guardian Drive, Philadelphia, PA 19104-6096.

0 1990 John Wiley & Sons, Inc. 0160-6891/90/050327-021 $04.00

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RESEARCH IN NURSING & HEALTH

ABSTRACT Discharge planning for the elderly can potentially reduce patient length of hospital stay, prevent rehospitalization, enhance patient outcomes and lessen the burden of care on the families. While increased numbers of elderly are being discharged earlier, there are few data on the process and effects of discharge planning protocols developed specifically for this population. The proposed study will attempt to answer the following questions regarding hospitalized elderly with selected DRG classifications: Are there significant differences between elderly patients who receive the hospital’s general discharge planning procedure used for all categories of patients and elderly who receive the hospital’s general discharge planning procedure plus a comprehensive discharge planning protocol specific to the elderly and implemented by a gerontological nurse specialist in: (1) Patient Outcomes (length of initial hospitalization; post-discharge morbidity; post-discharge health services; functional status; mental status; satisfaction with care; self-esteem; patient’s perception of health status; and stress level); (2) Family Related Outcomes (primary care giver’s functional status; mental status; care giving demands; stress level and family functioning); (3) Cost of Care Outcomes (charges for initial hospitalization, rehospitalizations, post-discharge health services; family related costs; and gerontological nurse specialist costs). The study design is a randomized clinical trial with a total of 280 elderly (2 groups of 140). The control group will receive routine discharge planning; the treatment group will receive routine discharge planning plus an elder-specific comprehensive discharge planning protocol. Data analysis will include frequency distributions and summary statistics. For each of the research questions, multivariate analysis of variance or chi-square statistics will be used.

SPECIFIC AIMS As a result of the introduction of Medicare’s Prospective Payment System in 1983, elderly are being discharged earlier from the hospitals. Discharge planning, considered fundamental to the effective delivery of health care for the elderly, can potentially reduce length of hospital stay, prevent rehospitalization, enhance patient outcomes and lessen the burden of care on the families. Unfortunately, while increased numbers of elderly are being discharged earlier, there are few data on the process and effects of a comprehensive discharge planning protocol developed specifically for this population. This proposal seeks to compare the effectiveness of a comprehensive discharge planning protocol developed specifically for hospitalized elderly and implemented by a gerontological nurse specialist to the hospital’s general discharge planning procedure. The effects of this protocol on patient outcomes, family related outcomes, and cost of care outcomes will be examined. The discharge planning protocol features the following services: a comprehensive assessment process which addresses the unique needs of the elderly; use of assessment data to project postdischarge service needs; and coordination, implementation, and evaluation of the discharge planning process in collaboration with the hospital’s discharge planning team. The population chosen for this study consists of hospitalized elderly experiencing common medical and surgical problems. The elderly represent an important group for study

since they occupy 40% of the hospital beds;’ experience earlier hospital discharge as a result of cost containment efforts; are a high risk group for complications associated with hospitalization; and represent a group in need of post-hospital services. The proposed study will attempt to answer the following question regarding hospitalized elderly with selected DRG classifications: Are there significant differences between elderly patients who receive the hospital’s general discharge planning procedure used for all categories of patients and elderly who receive the hospital’s general discharge planning procedure plus a comprehensive discharge planning protocol specific to the elderly and implemented by a gerontological nurse specialist in: 1. Patient Outcomes (length of initial hospitalization; post-discharge morbidity; post-discharge health services; functional status; mental status; satisfaction with care; self-esteem; patient’s perception of health status; and stress level) 2, Family Related Outcomes (primary care giver’s functional status; mental status; care giving demands; stress level; and family functioning) 3. Cost of Care Outcomes (charges for initial hospitalization, rehospitalizations, post-discharge health services; family related costs; and gerontological nurse specialist costs) This study is the initial phase of a program of research that will examine the effects of specialized protocols for the elderly, implemented by ger-

RESEARCH GRANT APPLICATION / NAYLOR

ontological nurse specialists in discharge planning and transitional care services. These services will begin with hospital admission and continue with home follow-up (home visits, telephone contact, and availability of nurse specialist to families) through the acute phase of the health problem. Effects on patient outcomes, family related outcomes, and cost of care will be examined throughout the research program. Data from this proposed study will provide valuable information regarding the effectiveness of a comprehensive discharge planning protocol implemented by a gerontological nurse specialist on the cost and quality of health services provided to hospitalized elderly as compared with the hospital’s general discharge planning procedure.

SIGNIFICANCE Framework The framework for this study is a conceptualization of a balance between the quality of care and cost of care in health services. This conceptual framework represents a modification of the three-variable framework of quality of care, including outcome, patient satisfaction, and cost proposed by Doessel and Marshall.2This proposed project uses a threevariable framework of cost, patient outcome. and family related outcome in which patient satisfaction is viewed as an outcome of the health service. The health service is discharge planning. The project framework also accepts McAuliffle’s3view that quality of care be conceptualized and measured in outcomes.

Background Introduction of Medicare’s Prospective Payment System, aimed at controlling health care costs, has resulted in reduced hospital length of stay for elderly patients. Patients are being discharged “quicker and sicker.” Unfortunately, patients may be discharged too early from the hospital and require rehospitalization or increased numbers of emergency or acute care visits by physicians or nurses. Additionally, patients may be discharged too sick or require care too complex for family members to manage.5 Earlier hospital discharge also may result in time lost from employment as family members assume the patient’s care. This shift in the burden of care and, to some extent, costs from hospitals and third party payors to patients and families holds potential for increased stress on both the financial and health status of patients and their families. All of these factors have increased the need for discharge planning,

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especially for those patients at high risk for poor post-discharge outcomes. Unfortunately, shortened lengths of hospital stay make timely and effective discharge planning more difficult to accomplish.

Discharge Planning and the Elderly People aged 65 and older comprise 11% of the U.S. population, yet at any given time, they occupy 40% of hospital beds.’ The National Discharge Hospital Survey shows that 11.2 million elderly patients were discharged in 1984. While elderly still tend to remain in the hospital more than 2 days longer than the average length of stay for all ages, the average length of stay for this population has decreased by 1.4 days since the introduction of the Prospective Payment System. Discharge planning beginning at the time of hospital admission is considered fundamental to the effective delivery of care in the elderly pop~ l a t i o n . ~ The . ” ~ hospitalized elderly must adapt to a strange routine, uncomfortable procedures, loss of privacy, and often radical alterations in role and self-image. When this stress is superimposed on grief for a recent loss, fear of loss of independence or of death, previous coping strategies may fail. Results may be inability of the elder to make adequate plans or absorb instructions prior to discharge or inability to recognize symptoms and deal with unexpected problems that arise following discharge.’ Previous research indicates that several variables are important in predicting post-discharge outcomes for hospitalized elderly: health professionals’ assessment of the elders’ health status; elders’ inability to maintain responsibility for their own health due to functional deficts, mental deficts, and emotional deficits (poor self-esteem); the use of community agencies prior to admission; elders’ own assessment of their general health with those perceiving their own health as good or excellent having better health outcomes post-discharge; and the presence of family and other social supports for assistance. lo After discharge, elders may be expected to need assistance longer than younger patients due to reduced ability to adapt to physical stress, need for a longer period of convalescence, and frequently, multiple chronic conditions requiring supervision, observation or care. Additionally, the elderly are least likely to have asiistance available to them after discharge. lo Elderly patients are more likely to live alone, to be cared for by an elderly spouse with disabilities that interfere with their ability to provide care or children who frequently have job and/or family responsibilities of their The role reversal that occurs when offspring become care givers is one of the most emotionally

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difficult of all transitions to make and a source of great stress to all in a family. Effective discharge planning is needed to facilitate timely hospital discharge and to find appropriate alternative care needed in order to prevent unnecessary readmissions, maintain health status of patients, and lessen the burden of care on families. Discharge planning should begin at the time of the patient’s admission to the hospital. It requires comprehensive assessment and recording of patient needs during hospitalization and projected needs post-discharge as well as coordination and implementation of the discharge plan. l 1 Unfortunately, much discharge planning currently suffers from delayed and inadequate assessment and planning, inadequate documentation, and fragmented implementation. I 2 . l 3 Studies of discharge planning indicate that it is often not a priority of physicians and nurses until the days immediately prior to patient discharge. 14* 5a, 5b. lo Information needed for successful discharge planning is often not recorded. Waters15b reported that overall, nursing assessments were incomplete, especially in relation to patient’s social circumstances. These findings support earlier work reporting 56% of discharge patients received no assessment of their home circumstances.l4 Some patients may receive no discharge planning. In one study of hospitalized elderly, only 20% received discharge planning by the social service department despite the fact that 86% of the patients were considered high risk patients in need of discharge planning according to the hospital’s own criteria. lo Implementation of the discharge plan may be quite fragmented. Assessment is often carried out in one institution and implementation in the patient’s home or another institution. There may be little or no continuity between the personnel carrying out the assessment and those implementing the care plan.

Approaches to Discharge Planning Throughout the last decade, there have been a number of approaches to discharge planning by health care professionals to improve the outcome to hospitalization for elderly patients. Logically, the elderly should receive discharge planning services by personnel knowledgeable in the care of the elderly for reasons of both effectiveness and efficiency of care. Currently, this group is receiving discharge planning services by various levels and types of personnel ranging from generalists with no special knowledge in gerontologic care to those who have specialized knowledge in the care of the elderly. In one of the earliest studies of discharge planning, Schrager, et a1.16 examined the effect

of physician and nurse referral of patients to a social worker for discharge planning within two days of patients’ admission. When the lengths of stay were compared for the control and referral patient groups, the patients referred for discharge planning were discharged an average of 5 days sooner than patients without hospital referrals. Not all discharge planning approaches, designed to facilitate early hospital discharge, however, have been found to be successful. Cable and Mayers” studied the effect of discharge planning on the length of stay in three community hospitals. With the onset of a discharge planning program, the length of hospital stay increased for patients with congestive heart failure, decreased for patients with cerebrovascular accidents, and resulted in a slight decrease in length of stay for patients with a hip fracture. The investigators concluded that the impact of discharge planning is specific to individual diagnoses. They also noted that while discharge planning may not have reduced length of hospital staffor patients with congestive heart failure, the quality of their discharge plans may eliminate or reduce their need for readmission. It is difficult to compare the results of Cable and Mayers work with previous or subsequent studies since the discharge planning program is not described nor is the type and qualifications of the individuals conducting the program. Kennedy, Neidlinger, and Scroggins18 evaluated the effects of a comprehensive discharge planning protocol implemented by a gerontological nurse specialist on one group of patients 75 years old and older. A control group of patients received routine discharge planning by the patient’s primary nurse assisted by other members of the health care team. Patients in the treatment group received the routine discharge plan by the patient’s primary care nurses plus gerontological nurse specialist services and comprehensive discharge planning developed specifically for the elderly. For patients in the treatment group, length of hospital stay was reduced by a mean of 2 days, and mean time between discharge and readmission was increased by 11 days. The difference of 1.9 days in the average length of stay was statistically significant. The readmission rate over 8 weeks of the study was 29% for the treatment group compared with 35% for the control group. An average difference of $1,3 11 in total hospital costs was found, with the control group being significantly more costly.

Use of Nurse Specialists While not specifically examining discharge planning, several investigators have examined the ef-

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ficacy of interventions by clinical nurse specialists (prepared with a master’s degree in nursing) in enhancing post-hospitalization outcomes. One recent study in which families of very low birthweight (VLBW) infants received discharge planning, earlier infant discharge and home follow-up services of a perinatal nurse specialist reported these findings: infants in the early discharge group were able to be discharged a mean of 11 days earlier, 200 grams less in weight and two weeks younger than the control infants; a mean savings in hospital charges of $18,560 for the early discharge group after subtracting the cost of nurse’s services; and no significant differences in numbers of rehospitalizations, acute care visits or measures of physical or mental growth between infants in the two groups followed for 18 months post hospital discharge.” In another study of home nursing care follow-up of patients with progressive lung cancer, the group of patients receiving care from oncology nurse specialists had fewer complications and rehospitalizations than the group followed by nurse generalists or groups receiving no home follow-up care.*’ Additionally, when home followup services were provided to post-myocardial infarction patients by nurse specialists, patients receiving the services of nurse specialists had significantly less psychological distress and were less dependent upon family supports than patients in the control group.21 These are but a few of the groups that could potentially benefit from the services of a nurse specialist in improving post-hospital outcomes. The elderly represent such a group. In summary, comprehensive discharge planning holds the potential for decreasing length of hospital stay for the elderly, preventing or delaying readmissions, improving health outcomes, and lessening family burden of care. Currently, discharge planning is not being conducted for all elderly patients. When it is, it is often incomplete and does not address the unique needs of the elderly and their families. The purpose of this proposed study is to compare the effectiveness of a comprehensive elder specific discharge planning protocol implemented by a gerontological nurse specialist and routine hospital discharge planning on patient outcomes, family-related outcomes, and cost of care outcomes.

PRELIMINARY STUDIES Dr. Mary Naylor, principal investigator, has been involved in health care of the elderly for over 15 years as a practitioner, educator, and researcher.

Dr. Naylor has taught content on the elderly at the undergraduate level and has been influential, through her consultation work, in integrating content on the elderly in many undergraduate curriculums in schools of nursing throughout the country. Dr. Naylor has authored many papers on the health care needs of the elderly, including a monograph, The Health Status and Health Care Needs of Older Americans, for the U.S. Senate Special Committee on Aging, Washington, D.C. From 1983 to 1986, Dr. Naylor had a W.K. Kellogg Leadership Fellowship; the primary focus of her national and international study during this period was public policy related to health care of the elderly. Additionally, Dr. Naylor has presented extensively, both nationally and internationally on the health care needs of the elderly. During the past few years, Dr. Naylor has been a professional staff member on the U.S. Senate Special Committee on Aging, a Fellow of the Center for the Study on Aging, and a Senior Fellow and member of the Executive Committee at the Leonard Davis Institute of Health Economics, University of Pennsylvania. The proposed study builds directly on Dr. Naylor’s most recently funded work, Comprehensive Discharge Planning for the Elderly. This preliminary work, funded by the Center for the Study of Aging, University of Pennsylvania and the University of Pennsylvania Research Foundation, focuses on modifying and refining the comprehensive discharge planning protocol for the elderly developed by Kennedy et al. Seed money was used to develop a conceptual framework and to refine protocols and procedures for use in the present proposed study. Consultation was obtained from experts in gerontology and instrumentation, resulting in incorporation of additional components to the protocol (i.e., assessment of patient’s mental status, self-esteem, perception of health status, assessment of primary care giver’s sociodemographics, general health status, perceived needs post-discharge, functional status, mental status, and validation of learning through return demonstration by a gerontological nurse specialist). Dr. Dorothy Brooten, co-investigator, has been involved in the area of early discharge and discharge planning for the past 8 years as a researcher. The proposed study builds directly on Dr. Brooten’s most recent published research. This study was a randomized clinical trial of early hospital discharge and nurse specialist home follow-up of very low birthweight infants (VLBW; S 1500 grams). The purpose of this study was to determine the safety, efficacy, and cost savings of early hospital discharge of VLBW infants provided discharge

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planning and home follow-up by a nurse clinical specialist. Infants in the early discharge group were discharged a mean of 11 days earlier, weighted 200 grams less, and were 2 weeks younger at discharge than control infants. The mean hospital charge for the early discharge group was 27% less than that for the control group, and the mean physician’s charge was 22% less. The mean cost of the nurse specialist home follow-up care in the early discharge group was $576, yielding a net savings of $18,560 for each infant. The two groups did not differ in the number of rehospitalizations and acute care visits or in measures of physical and mental growth. The study was published in the New England Journal of Medicine. l 9 Currently, .Dr. Brooten is principal investigator of a research program project grant on early hospital discharge and nurse specialist follow-up of three patient groups. The study will examine effects of early hospital discharge and nurse specialist follow-up on patient outcomes and cost of care. Dr. Mark Pauly, co-investigator, is Professor, Health Care Systems, Public Policy and Management, The Wharton School, and Executive Director of the Leonard Davis Institute of Health Economics, University of Pennsylvania. Dr. Pauly has published numerous books and articles in a variety of refereed research journals (including JAMA, Inquiry, and Research in Health and Economics) on medical care and medical insurance, public finance, and insurance theory. Dr. Pauly also has presented extensively, both nationally and internationally, including papers on “Medicare DRG Regulation and its Effects on the Elderly and the Uninsured Poor,” “Cost Containment and New Directions in Health Policy in the US.:Some Answers and Some Questions,” and “The Cost/ Quality Conflict: How It Affects the Patient.” Dr. Pauly is an active member of the Institute of Medicine and has been an economic consultant to numerous groups including the Hospital Research Foundation and Health Research and Educational Trust of New Jersey’s Office of Health Policy Analysis. Dr. Risa Lavizzo-Mourey , co-investigator, is Assistant Professor in the School of Medicine and the Wharton School, University of Pennsylvania. Dr. Lavizzo-Mourey has been involved in health care of the elderly for the past 8 years as a clinician, educator, and researcher. She has published several papers on the special medical needs of the elderly and has, in press, a clinician handbook on prevention and health promotion for the elderly. Dr. Lavizzo-Mourey is a member of the National Committee on Preventive Health Services for the

Elderly. Her currently funded research includes “Nursing Home Infirmaries: A Cost Saving Strategy,” funded by the Robert Wood Johnson Foundation for $89,000. This 3-year project is aimed at evaluating the costs, outcomes, and feasibility of caring for acutely ill nursing home patients in a nursing home based infirmary. A second study, “Risk Factors for Dehydration Among the Elderly,” examines dehydration in nursing home residents using epidemiologic techniques. Dr.Mathy Mezey, co-investigator, is Professor, Gerontological Nursing, University of Pennsylvania and Senior Program Consultant and Program Director, The Teaching Nursing Home Program funded by the Robert Wood Johnson Foundation. Dr. Mezey has been involved in the area of health care for the elderly for over 10 years as a practitioner, educator, and researcher. Dr. Mezey has published extensively on the special health care needs of the elderly in numerous refereed journals, including Nursing Outlook, Journal of Nursing Education, and the Journal of the American Geriatrics Association. Dr. Mezey has presented numerous papers, both nationally and internationally, on the special needs of the elderly including “Gerontological Nursing” and “Education Practitioners for the Care of the Elderly.” Dr. Mezey’s past research has included the following: Career Preparation in Gerontology (principal investigator); Teaching Nursing Home Program (program director and senior program consultant); and Issues Surrounding Hip Fracture in Older People: A Preliminary Study (co-principal investigator). Dr. Robert Jones, co-investigator, is Associate Professor, Department of Statistics, the Wharton School, and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania. Dr. Jones has published in a variety of refereed research journals, including JAMA and the American Journal of Medicine, on economic benefits and health education and promotion activities. Dr. Jones also has presented nationally and internationally on statistical topics. He has been a statistical consultant on the Annals of Internal Medicine and a reviewer for a number of publications such as JAMA and Preventative Medicine-An International Journal.

METHODS Design The study will use a randomized clinical trial to compare the effectiveness of a comprehensive discharge planning protocol developed specifically


for the hospitalized elderly and implemented by a gerontological nurse specialist to the hospital’s general discharge planning procedure. Elderly with selected DRG classifications and their family related members will be followed for 2 weeks posthospital discharge by a gerontological nurse specialist; data collection will extend to 3 months post-hospitalization. Differences in patient outcomes, family-related outcomes, and cost of care outcomes will be examined in both groups (Figure 1).

Sample The projected number of eligible cases for the timeline of the study permits the investigators to detect (at a two tailed a = .05) minimum treatment effects ( f = .20 for comprehensive discharge planning protocol effects; f = .20 for DRG classification effects;f = .20 for interaction effects), with a statistical power of .80.22Specifically, a sample size of 280 is targeted (35 subjects from each of the four major DRG categories in the control group and, equally, 35 subjects from each of the four major DRG categories in the treatment group). An oversampling of 20% (n = 336) will account for subject attrition and assure an adequate sample size. Subjects will be randomly assigned to control ( N = 140)and treatment (N = 140) groups. Elderly who are: 70 and older, admitted to medical or surgical units (excluding intensive care units) at the Hospital of the University of Pennsylvania (HUP) with the primary DRG classification of simple pneumonia or pleurisy (DRG 89); congestive heart failure (DRG 127); hip fracture (DRG’s 209, 210); and cardiac surgical disorders (DRG’s 104, 105, 106, 107, 108, 117, 118); alert and oriented at admission; English speaking and able to respond to questions; admitted from home since these patients are more likely to be discharged home; and able to be reached by telephone postdischarge will be eligible for the study. Only those subjects who are discharged to home will be included in the study. The two medical and two surgical diagnoses selected for this study are among the 10 most common DRG categories for all hospitalized elderly in 1986.5 A total of 462 patients 70 years and older were admitted to HUP in fiscal year 1987 in the study DRG categories. This represents 80 patients in the category of simple pneumonia and pleurisy, 81 patients in congestive heart failure, 178 patients in cardiac surgery, and 123 patients in hip fractures. Based on previous work with this

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population and on data from the social service department at HUP, approximately 80% of patients in these DRG categories are discharged home, English spealung, and have telephones. This results in a potential total of 370 subjects available annually who have been discharged home. On a monthly basis, 5 subjects meeting study criteria should be available in the category of simple pneumonia and pleurisy, 5 subjects in congestive heart failure, 12 subjects in cardiac surgery, and 8 subjects in hip fractures. Given the availability of subjects per month, an adequate sample size (70 subjects per DRG) should be reached in 24 months. If difficulty is encountered in a particular DRG, data collection can be extended to 30 months for that DRG . Family-related members also will be included in this study. Family-related is used broadly to include biologic family members, relatives by marriage, or friends that the patient identifies as important. For the purpose of this study the primary care giver is a family related member who will be primarily responsible for the care of the patient in the home after hospital discharge. Family related members must be able to read and write English and be able to be reached by telephone. It is conceivable that a small number of subjects will not have a primary care giver. These subjects will not be excluded from the study, however. Comparison of patient outcomes and cost of care will be made between this subgroup and subjects with family related members. Based on previous research, more than two-thirds of the sample will have a primary care giver.13

Procedure Subjects meeting the study criteria will be identified within 24 hours of admission by a project manager. The manager will identify potential subjects using the hospital’s daily admission summary and through consultation with nursing staff. When eligible subjects have been identified the manager will meet with the patient, explain the study’s purpose, and obtain consent. For patients who have difficulty seeing or hearing, the manager will arrange to have the hospital’s patient advocate available during the process of obtaining consent (Appendix B). During the consent interview, the patient will be asked to identify hidher primary care giver. If this individual is present, the family related component of this study will be explained and consent obtained (Appendix B). If the primary care giver is not present, helshe will be contacted by telephone and a visit with the manager will be

Procedure Developed for All Patients

Hospitalized Elderly With General Discharge Planning Plus Comprehensive Discharge Planning Protocol Developed for Elderly Implemented by Gerontological Nurse Specialist

TREATMENT GROUP

FIGURE 1. Study model

tal Status 3. Caregiving Demands on

Hospitalized Elderly

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Family Related Outcomes 1. Primary Care Giver's

CONTROL GROUP

Patient Outcomes 1. Length of initial hospitalization 2. Post-discharge morbidity a. Infection b. Rehospitalization 3. Post-discharge health services 4. Functional status 5. Mental status 6. Satisfaction with care 7. Self-esteem 8. Patient's perception of health status 9. Stress level

Home

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Cost of Care Outcomes 1. Initial hospitalization 2. Rehospitalization 3. Post Discharge Health Services 4. Family related costs a. Patient out-of-pocket costs b. Primary care giver costs 5. Gerontological Nurse Specialist costs

5. Family Functioning

tal Siatus Caregiving Demands on Primary Care Giver 4. Primary Care Giver Stress

Family related Outcomes 1 . Primary Care Giver's Functional Status 2. Primarv Care Giver's Men-

Patient Outcomes 1. Length of initial hospitalization 2. Post-discharge morbidity a. Infection b. rehospitalization 3. Post-discharge health services 4. Functional status 5. Mental status 6. Satisfaction with care 7. Self-esteem 8. Patient's perception of health status 9. Stress level

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scheduled to explain the study and obtain consent. Following informed consent, subjects will be randomly assigned using the sealed envelope technique, to either a control or treatment group. The research assistant initiates data collection on both the control and treatment groups at patient’s admission and continues through 3 months posthospital discharge (See Table 2 in Appendix A). Within the first 24 hours of admission, a research assistant will complete the following instruments on patients in both the control and treatment groups: standardized data form that documents patient’s sociodemographics, general health status, prehospitalization resource use pattern, and patient’s perceived needs post-hospitalization (Appendix F); functional status (Enforced Social Dependency Scale Appendix G ) ; mental status (Mini Mental State Examination Appendix H); self-esteem (Rosenberg’s Self-Esteem Scale Appendix I); patient self-assessment of health status (Health Perceptions Questionnaire Appendix J); stress level (Multiple Affect Adjective Checklist-R, Appendix K). Within the first 24 hours of admission the research assistant will complete the following instruments on the primary care giver in both the control groups and treatment groups: standardized data form that documents the primary care giver’s sociodemographics, general health status, and perceived needs post patient discharge (Appendix L); functional status (Enforced Social Dependency Scale); and mental status (Mini Mental State Examination). The maximum amount of time it will take patients to complete questionnaires, at any one data point, is 45 to 60 minutes. For primary care givers the maximum time is 30 to 45 minutes. To facilitate completion of questionnaires, subjects will have opportunity to rest between questionnaires, if needed, in order to maintain subject attention and interest. To aid in data collection, a $30 gratuity will be provided to subjects ($15 to patient; $15 to primary care giver) at the study’s completion. Recently, the National Institutes of Health Consensus Development Conference recommended that studies using comprehensive geriatric assessment be conducted comparing outcomes on elders who are treated using these data with elders on whom such data are not used.” In the proposed study, the nurse specialist uses such data to implement the discharge planning protocol in the treatment group.

Protocols Control group. Subjects in the control group will receive the general discharge plan used for

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all categories of patients. The major components of the discharge planning process used at HUP are as follows: the primary nurse assigned to the patient initiates a discharge plan at the time of admission; assesses, plans, coordinates and evaluates the nursing component of the discharge plan; makes appropriate referrals to the multidisciplinary team in a timely manner; and directs the involvement of auxiliary staff in the implementation of the discharge plan. Responsibility for implementation of discharge planning at HUP is divided between nurse discharge planners and social workers. While the hospital has a preferred provider arrangement with several home care agencies, the process for discharge planning is conventional; assigned hospital personnel decide, based upon their individual judgment and patients’ risk (Appendix C), who should be approached for discharge planning. Appropriate personnel then contact community agencies to arrange for services. The discharge ‘planning procedure used at HUP is described in Appendix C. Treatment group. Subjects in the treatment group will receive all components of HUP’s general discharge planning procedure. In addition, this group will also receive the comprehensivedischarge planning protocol developed specifically for the elderly and implemented by the gerontological nurse specialist (Appendix D). The use of a comprehensive discharge planning protocol assures that attention is paid to the unique needs of the elderly in a systematic manner. The comprehensive discharge planning protocol is a modification of that developed by Kennedy et al. l8 (Appendix E). The following components were added to the Kennedy et al. protocol: assessment of patient’s mental status, self-esteem, perception of health status; and, assessment of primary care giver’s sociodemographics, general health status, perceived needs post-patient discharge, functional status, mental status; formalized individual patient and primary care giver teaching plans; and validation of learning through return demonstration to a gerontological nurse specialist. In addition, the procedure by which this comprehensive discharge planning protocol was modified includes a minimum of four visits by the gerontological nurse specialist in the hospital and telephone availability during hospitalization and in the first 2 weeks post-hospital discharge. As compared with the hospitals’ (HUP) routine discharge planning procedure used for all hospitalized patients, the unique features of this comprehensive discharge planning protocol implemented by a gerontological nurse specialist include:

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Comprehensive assessment of the unique needs of the elderly patient and hidher primary care giver within 24 hours of admission using data from reliable and valid instruments as baseline information; Use of assessment data to project the elderly patients’ and primary care givers post-discharge needs within 24 hours of admission; Validation of elderly patient’s and primary care giver’s learning through return demonstration; Evaluation and modification of the discharge plan within 24 hours prior to discharge and continued follow-up for 2 weeks post-discharge; A minimum of four visits by the gerontological nurse specialist during the patient’s hospitalization for the purpose of discharge planning; and Availability of a gerontological nurse specialist by telephone during and following hospitalization and a minimum of two nurse specialist initiated telephone contacts to the patient within the first 2 weeks post hospital discharge.

The use of a master’s prepared gerontological nurse specialist assures that this protocol is being implemented by an individual with advanced knowledge and skills in the care of the elderly and their families. In addition to being master’s prepared in gerontological nursing, these nurses will have a minimum of 1 year of clinical practice as a gerontological nurse specialist. The gerontological nurse specialist will make a minimum of four visits during the patient’s hospitalization. The nurse specialist will see all subjects within 24 hours of admission to: complete patient and primary care giver assessment; develop an initial discharge plan for subjects in collaboration with patient, family, physician and other health team members; and record a summary of the discharge plan on the subject’s chart (Visit 1). The nurse specialist will make a minimum of two additional visits during the hospitalization to develop the patient’s and primary care giver’s teaching plan; conduct or collaborate with the primary nurse in implementing the teaching plan; conduct all patient and primary care giver return demonstrations to validate learning; and coordinate home care services. The gerontological nurse specialist will provide each patient and primary care giver with a 2-hour per day, 7-day per week schedule of telephone availability hours. The nurse specialist will be available during these times to answer questions and concerns regarding the discharge plan. The gerontological nurse specialist will see all subjects within 24 hours prior to hospital dis-

charge to evaluate and make modifications in the discharge plan (Visit 4). The nurse specialist will initiate a minimum of two telephone calls during the first 2 weeks after discharge to monitor the adaptation of the patient and primary care giver to home and to modify the discharge plan as necessary. The gerontological nurse specialist will complete the following comprehensive discharge planning protocol for subjects in the treatment group (Table 1 in Appendix A): 1. Assessment of Patient’s and Primary Care Giver’s Discharge Needs Patient assessment. With the following data gathered from the patient as the base (sociodemographics, general health status, prehospitalization resource use pattern, perceived needs posthospitalization, functional status, mental status, self-esteem, perception of health status and stress level) the gerontological nurse specialist will complete a thorough assessment of the patient’s needs post-hospitalization, within 24 hours of the patient’s admission. Primary care giver assessment. With the data gathered from the primary care giver as base (primary care giver’s sociodemographics, general health status, perceived needs post-patient discharge, functional status, and mental status) the gerontological nurse specialist will complete a thorough assessment of the primary care giver’s needs post-hospitalization, within 24 hours of the patient’s admission. 2. Documentation of Patient ’s/Primary Care Giver’s Discharge Needs Within 24 hours of admission, the gerontological nurse specialist will use the assessment data to project the patient’s and primary care giver’s postdischarge home care needs. The nurse specialist will discuss the proposed plan with the patient, family, physician, and other health team members. The plan will be updated and revisions made as necessary during the patient’s hospitalization. A summary of the discharge plan will be recorded on the patient’s progress notes and a copy of the plan will be maintained by the investigators. 3. Implementation of Discharge Plan Teaching. The gerontological nurse specialist will develop the discharge teaching plan for both the patient and the primary care giver. This teaching plan will be based on patient-specific health problems and the unique learning needs of the patient and the primary care giver. For example, a patient who has undergone hip surgery will require assistance with ambulation, incisional care, etc. Because an 80-year-old patient also may have visual


deficits, this patient and his primary care giver will require special instructions to promote safety in ambulation and to prevent falls. Based on the teaching plan developed by the gerontological nurse specialist, the patient’s primary nurse and nurse specialist will collaborate regarding who will actually conduct the patient and primary care giver teaching. The primary nurse or gerontological nurse specialist may conduct all or a portion of the teaching. A copy of the teaching plan will be included on the patient’s chart and a copy will be maintained by the investigators. Validation of learning. Validation of both patient and primary care giver’s learning, via return demonstration, will be completed by the gerontological nurse specialist. Documentation of the patient’s and primary care giver’s learning will be recorded on the patient’s and primary care giver’s teaching plan. Coordination of home care services. The gerontological nurse specialist will collaborate with the patient’s physician, the hospital’s discharge planner, and other appropriate personnel in arranging for the patient’s home care needs (i.e., nursing, physical therapy, etc.). These data also will be recorded on the patient’s discharge plan. 4. Evaluation and Modification of Discharge Plan The gerontological nurse specialist will visit the patient within 24 hours prior to discharge to evaluate the discharge planning process and make revisions if necessary. If the patient is discharged precipitously before this evaluation visit is made, either a home visit or telephone follow-up will be made. The nurse specialist will contact the patient and primary care giver via telephone at least twice during the first 2 weeks after discharge to address any questions or concerns associated with the discharge plan. The first telephone call will be made between 24 and 48 hours after discharge. This process has been demonstrated to be successful with other patient populations. l 9 Patients and primary care givers need approximately 24 hours at home to readjust following hospitalization; at this time they can identify questions, concerns. and additional needs associated with care at home. A second telephone call will be made at approximately 1 week post-discharge to continue monitoring the patient’s and primary care giver’s adaptation to home and to make additional revisions in the plan, if necessary. Any changes in the plan will be communicated to appropriate personnel such as the physician or agencies such as the home health agency and recorded on the discharge plan.

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DATA COLLECTION Data on patient outcomes, family-related outcomes, and cost of care outcomes will be collected from both the control and treatment groups. The study variables and instruments, variables and data points and study timetable are listed in Tables 2, 3, and 4 in Appendix A. Patients must be alert and oriented at the time of admission. Subjects who experience physical, emotional, or mental problems after admission which prevent them from completing all interviews will not be deleted from the study; available data will be collected from these subjects. Post-discharge, if a subject’s hearing is a problem, face-to-face interviews in the home may be used. Patient outcomes will include length of initial hospitalization, post-discharge morbidity (infection, rehospitalization), post-discharge health services (visits by patients to health care providers and visits by health care providers to patients), functional status, mental status, satisfaction with care, self-esteem, patient’s perception of health status and stress level. Length of initial hospitalization will be collected at discharge via chart audit. Data on post-discharge morbidity and postdischarge health services will be collected at 2, 4, and 12 weeks post-discharge. Data on morbidity (infection, rehospitalization) will be collected from the patient via telephone interview. Data on postdischarge health services will be obtained via telephone interview with the patient and a record maintained by the patient (or a proxy, if needed). These data will be validated by telephone interview with the patient’s attending physician and a review of the patient’s discharge plan. Data on patient’s functional status, mental status, self-esteem, patient’s perception of health status and stress level will be collected at hospital admission and discharge and at 2, 4, and 12 weeks post-discharge. Data on satisfaction with care will be collected at discharge and at 2 , 4 , and 12 weeks post-discharge. All of these data will be collected via face-to-face interview with patients in the hospital and via telephone interview with patients following discharge. Family related outcomes will include primary care giver’s functional status, mental status, care giving demands, stress level, and family functioning. Data on functional status and mental status will be collected at the patient’s hospital admission, discharge and at 2,4, and 12 weeks post-discharge. These data will be collected from the primary care giver via face-to-face interviews during the patient’s hospitalization and via telephone interviews after the patient’s discharge. Data on the care giving

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demands, stress level, and family functioning will be collected from the primary care giver at the patient’s hospital discharge via face-to-face interviews and at 2 ,4 , and 12 weeks post-discharge via standard telephone interviews. Cost of care outcomes. will include charges for initial hospitalization, rehospitalizations, postdischarge health services; family related costs; and gerontological nurse specialist costs for the treatment group. Charges for initial hospitalization will be collected from copies of patients’ bills generated by HUP’s cost accounting system after initial hospital discharge. Charges for rehospitalization will be collected at 12 weeks post-discharge from copies of patients’ bills generated at the hospital where the patient was readmitted after hospital discharge. Charges for post-discharge health services (visits by patient to emergency room, clinic or physician’s office or visits to patient’s home by nurses, physical therapists, home health aids, etc.) will be collected at 2 , 4, and 12 weeks post-discharge via telephone interview with the patient and from a record maintained by the patient (or proxy, if needed). The need for post-hospital health services will be validated by a telephone interview with the patient’s attending physician and a review of the patient’s discharge plan. Family related costs will include out-of-pocket patient costs [costs for medication, transportation to and from post-discharge health services (i.e., physician’s offices, clinics) private nursing and health aid workers, special equipment and supplies and miscellaneous out-of-pocket costs]. Data on patient out-of-pocket costs will be collected via interviews with the patient (or proxy, if needed). In addition, the patient will be asked to maintain a record of all out-of-pocket expenses and receipts for these expenses up to 12 weeks after discharge. The need for out-of-pocket services will be validated by a telephone interview with the patient’s attending physician and a review of the patient’s discharge plan. Costs of caring for the elderly patient at home incurred by the primary care giver include the time devoted by the primary care giver to patient care; patient care related costs (transportation to and from patient’s home, child care, telephone costs, etc.); and changes in the primary care giver’s pattern or type of employment (job title, hours worked per week). Data on time devoted to direct patient care after discharge will be collected from the primary care giver via telephone interviews at 2,4, and 12 weeks; baseline data will be collected prior to hospital discharge. The investigators will use the same procedure to collect data regarding

patient care-related costs and changes in the pattern and type of employment. Costs of gerontological nurse specialist services will be calculated at the completion of the discharge protocol. The time that the gerontological nurse specialist devotes to the protocol will be recorded by the nurse specialist. All direct care, consultative, preparatory, administrative, and telephone time will be recorded. The nurse will not only identify total time devoted to the protocol for each patient, but also record the number of minutes for each patient-related action and interaction. The methodology that will be used to convert time to costs is described in the instrumentation section of this study.

INSTRUMENTS Table 1 in Appendix A presents the major study variables and instrumentation.

Patient Outcomes The variables judged to be central to patient outcomes in this study are length of hospitalization, post-discharge morbidity, use of post-discharge health services, functional status, mental status, satisfaction with care, self-esteem, patient’s perception of health status and stress level. Patient outcomes will be measured as follows: 1. Length of initial hospitalization-Length of initial hospitalization will be documented via chart review. A standardized data form will be used to record the length of stay for initial hospitalization and patient demographics (Appendix P) . 2. Post-discharge morbidity-The number and types of infections and rehospitalizations will be used to measure post-discharge morbidity and will be operationalized in the following manner: a. Infection: A standardized data form for infections will include subject number, date diagnosis, nature of infection, treatment and date of termination of infection (See Appendix P). b. Rehospitalization: A standardized data form will be used to record subject number, date of rehospitalization, reason for rehospitalization (diagnosis), date of discharge, and total length of rehospitalization (Appendix R). 3. Post-discharge health services-Standardized data collection forms will be used to record subject number, date of visit, reason for


visit, treatment, and length of visit (See Appendix S). 4. Functional status-The patient’s functional status will be measured using the Enforced Social Dependency Scale (ESDS; Appendix G ) . 2 3Enforced social dependency is defined as needing help or assistance from other people in order to perform activities or roles that under ordinary circumstances adults can do by themselves. Many measurements of functional status typically associated with the elderly population were reviewed (i.e., The Barthel-Index; Katz Index of Activities of Daily Living). The revised ESDS was selected for use in this study because it measures social as well as personal competence. Personal competence comprises six activities judged central to performing as a normal adult: eating, dressing, walking, traveling, bathing, and toileting. Each activity is coded on a 6-point Likert-type scale. Scores for personal competence are summed, ranging from 6 to 36. Social competence comprises four categories judged central to performing as a normal adult; level of consciousness, role activity, role interest, and role contact or interaction. Three specific social roles are included: spouse, work, and recreational roles. Each activity for social competence is coded on a Likert-type scale from 1 to 4. Scores for social competence are summed, ranging from 4 to 15. Scores for the total ESDS range from 10 to 5 1. A socially independent person with no restriction could receive a score of 10, and a person with maximum social dependence could receive a total score of 5 1. The original scale, developed in 1978, has been revised and tested with a variety of patient groups. Test-retest reliability was .62 and in other studies have been reported to be .76.24-25 Chronbach’s alpha has been reported from a low of .78 to a high of .92? The revised scale has been tested on a number of populations including several samples of elderly patients. 25.26.27 The validity of the ESDS is supported by factor analysis that has confirmed the two unique factors of personal and social Competence. Additionally, Fink reported a high correlation between the ESDS and the Sickness Impact Profile.26 The psychometric properties of the ESDS continue to be investigated. The reliability and validity data currently available suggest that the instrument is an objective measure of the two dimensions of functional status that are of interest in the study. The investigator plans to determine the reliability and validity of the ESDS with this study population. For example, factor analysis will be used to determine the content validity of the ESDS, the factor matrix will be compared with McCorkle

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and Benoliel’s work. The ESDS only takes 10 to 20 minutes to administer. It is a semi-structured interview guide, allowing the subject to share his/ her perception of what is happening. Because the first question is general and open-ended, the subject often gives enough information to allow rating on the item without resorting to further questions. Responses are scored in a standardized way that enables comparison across time and across groups. The scale has been shown to be sensitive to change over time. 5. Mental status-The Mini-Mental State Examination (MMSE) (Appendix H) is a screening instrument which established psychometric properties including adequate evidence of reliability and validity that separates patients with cognitive disturbances from those without such disturbances.28 The MMSE begins with a graded assessment of orientation to place and time followed by tests of two aspects of memory. A maximum of 21 points may be scored on this section of the test. The final section tests for the presence of aphasia and apraxia; a maximum of 9 points may be obtained on this section, for a total possible MMSE score of 30 points; a score of 23 or less indicates the need for further assessment. The MMSE is easily administered, is well tolerated by patients, and can be completed within 10 minutes or less. Discriminant validity of the MMSE was documented when given to normal subjects and patients with dementia, affective disorders, and personality disorders. Its scores correlated with the Weschler Adult Intelligence Scale, Verbal and Performances scores (MMSE vs. Verbal IQ, Pearson r = .77 ( p < .001); MMSE vs. Performance IQ, Pearson r = .66 ( p < .001). The MMSE 24 hours and 28 day test-retest (r = .88) and interrater (r = .82) reliabilities are adequate. 29 6. Satisfaction with care-The LaMonicaOberst Patient Satisfaction Scale (Appendix M) will be used to measure satisfaction with care.3o This scale is a revision of the Risser scale.31 It is intended to be reflective of care in an acute care setting. Satisfaction with nursing care is defined by the authors as “the degree of congruence between patients’ expectations of nursing care and their perceptions of care actually received.” Three samples were used to determine the psychometric properties of the in~truments.~~ Content validation procedures included both nurses and patients. An inverse relationship of satisfaction scores to negative mood states demonstrated evidence for construct validity. Three factors were identified through the use of factor analysis: dissatisfaction, interpersonal support, and good

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impression. The internal consistency reliability coefficients for these three subscales were high (alpha = .91, .92, and .89). Reliability coefficients for the total instrument in successive testings were .92 and .95. The tool was selected for use in this study because of the relevance of the items to the subjects in the study and the ease with which it can be administered; it can be completed in 810 minutes. The instrument contains 41 items that are rated on a five-point scale from strongly agree to strongly disagree. The potential range of scores for the total scale is 41-205. 7. Self-esteem-The Rosenberg Self Esteem Scale (Appendix I) will be used to measure selfesteem.32The scale was devised to achieve a unidimensional measure of global self-regard. The scale consists of 10 items answered on a fourpart Likert response scale ranging from strongly agree to strongly disagree. Positively and negatively worded items were used to reduce the response set. The total score reflects the degree of positive self-esteem. Silbur and T i ~ p e t tobtained ~~ a 2week test-retest coefficient of .85 for the scale and supported its concurrent validity through correlation with three other measures of self-esteem. The Rosenberg Self-Esteem Scale was selected for use in this study because it directly measures a person’s general sense of self-worth and selfacceptance and because of its ease of administration. The scale requires only 2 to 3 minutes to complete, simply requiring a check for each answer. 8. Patient’s perception of health status-Patient’s perceptions of their health status will be measured using the Health Perceptions Questionnaire (HPQ) (Appendix J).34 The HPQ measures the following constructs: current health; prior health; health outlook; resistance to illness; health wonylconcern, and sickness orientation. Each of the 32 items form the HPQ is a complete statement of opinion worded favorably or unfavorably about personal health or health related perceptions. Five responses accompany each item ranging from definitely true to definitely false. The 32 items are distributed among the 6 scales yielding scores on 6 dimensions of health status perception. Data on the psychometric properties of the HPQ were obtained from five field tests involving approximately 2,000 adult respondent^.^^ The samples of these studies differed widely in social and economic characteristics and the replications support generalization of findings regarding scale development. Both internal consistency and testretest reliability estimates exceed the acceptable minimum of .50 and indicate that the six HPQ scales are reliable for group comparisons. Reliabilities for the Current Health scale were all above

.85; those for the Health Outlook scale were generally in the .60 to .70 range. The Health Worry/ Concern scale and the Sickness Orientation scale had reliabilities ranging from .50 to the mid .60’s.36337 Content validity of the HPQ was supported by factor analysis. Additionally, HPQ scores correlated significantly with other health variables such as number of sick days (an inverse correlation). 9. Stress level-The patient’s stress level will be measured by using the Multiple Affect Adjective Check List-Revised State Form (MAACL-R) (Appendix K).38 For this study, the conceptualization of stress described by Elliot and Eisdorfer is used in which anxiety, depression and hostilit are viewed as psychologic reactions to stress. 39g The MAACL-R consists of 132 affect connoting adjectives and provides measures of self-reported moods. Based on recent factor analyses, the original Anxiety, Depression, and Hostility scales were changed from bipolar to briefer unipolar scales. A new composite score (Anxiety, Depression, and Hostility) is labeled Dysphoria. Norms for the state form of the MAACL-R have been reported for a college sample by Zuckerman and Lubin. The internal consistency estimates (coefficient alphas) are adequately high. Across the scales, relevant to this proposal, the median internal reliability estimate over eight samples were reported by Lubin et al. as .85 (range = .69 to .95). The test-retest reliabilities of the state form for five scales were appropriately low, indicating their sensitivity to change of mood. The pattern of correlations among self, peer, and counselor ratings and the MAACL-R scales for normal and patient samples generally indicated improved discriminant validity and e ually good convergent validity as the old scales. In addition, the use of standard scores that are indexed to the number of items checked by subjects reduced scale intercorrelations by controlling the acquiescence set.

9

Family Related Outcomes The variables that will be examined in relationship to family outcomes are: the primary care giver’s functional status, mental status, care giving demands, stress level, and family functioning. These variables will be measured as follows: 1. Primary care giver’s functional statusThis variable will be measured using the Enforced Social Dependency Scale (Refer to Patient Outcomes for discussion of instrument). 2. Primary care giver’s mental status-This variable will be measured using the Mini-Mental


State Examination (Refer to Patient Outcomes for discussion of instrument). 3. Care giving demands on the primary care giver-The care giving demands on the primary care giver will be measured using the Care Giving Inventory (Appendix N).40The Care Giving Inventory consists of 40 items that are positively and negatively worded with five responses ranging from strongly agree to strongly disagree. The inventory is easily administered and can be completed in 5 to 10 minutes. The validity of the Care Giving Inventory is supported by Stetz who documented the demands of caring for a spouse at home with advanced cancer using content analysis of an openended questionnaire. Eighteen mutually exclusive care giving demand categories were identified from the analysis of spouse care giver responses to the question, “Sometimes persons caring for their spouse encounter situations that are difficult for them; what things about this experience are difficult for you?’ Interrater reliability between two independent coders reached 89% agreement on the assignment of documented demand statements to the 18 categories. The 18 categories were then collapsed into 9 large categories by content area. The demands reported most frequently (69% of the sample) were managing the physical care, treatment regimen, and imposed changes. The second most frequently reported care giving demand category (39%) was managing the household and finances. Questions regarding each of these categories comprise the Care Giving Inventory. The internal consistency reliability of the Care Giving Inventory has been reported at .78. 4. Primary care giver stress level-This variable will be measured using the Multiple Affect Adjective Check List-Revised State Form (MAACL-R). (Refer to patient outcomes for discussion of instrument) 5. Family functioning-Family functioning will be measured using the Family Apgar Scale (Appendix O).41This scale was devised as a utilitarian tool that measures a family member’s perception of five dimensions of family functioning: adaptation, partnership, growth, affection, and resolve. This tool consists of five items that are each answered on a 3-point scale. The concurrent validity of the Family Apgar was established by correlations with scores on the Pless-Satterwhite Family Function Index ( r = .80)42 and by comparing therapist ratings of family functioning with scores obtained from family members on the Family Apgar ( r = .64). Discriminant validity was supported in a study in which married graduate students had significantly higher Family Ap ar scores than did mental health clinic patient^.^

F

34 1

Cronbach alpha reliability (.go) was determined from data obtained from college students. Testretest reliability on 100 Taiwanese students was .83. This self-report inventory has been used successfully in general medical clinics and normative data are available on this population as well as student and psychiatric patient group^.^' Scores on the Family Apgar Scale may range from 5 to 15 with a higher score indicating more positive family functioning. The ease with which this tool can be answered (the developers found children as young as 10 could easily respond to the questions) and the robustness the tool has demonstrated when used with various cultural groups are the prime reasons it was chosen for this ~ t u d y . ~ ” ~ ~

Cost of Care Outcomes 1. Charges for initial hospitalization and rehospitalization-Charges for initial hospitalization will be collected from copies of patients’ bills generated by HUP’s cost accounting system after initial hospital discharge. Data from these will be recorded on a standardized data form (Appendix P). Charges for rehospitalizations will be collected from copies of patients’ bills generated after discharge by the hospital where the patient has been readmitted and recorded on a standardized data form (Appendix R). Charge data will be used for this study. Actual cost data will not be readily available for daily hospital services, ancillary hospital services (such as lab tests and x-rays, etc.), and physician services. Hospital bills provide charge information by revenue center. These data will give us information on the number of days in each unit, and the charge for each ancillary service. The bill used by HUP is quite detailed, providing separate charge information on each type of lab, for example, rather than lumping all laboratory charges together. It is widely recognized that there are a number of methodological problems with the use of charge data in cost analysis.44 Charges include both fixed and variable costs. Fixed costs may not fall as output is reduced. Furthermore, methods of cost allocation may fail to accurately assign costs to patients who were responsible for consumption of specific resources. While charge data do not provide highly accurate measures of true cost of treatment, the information is still quite valuable and useful. Clearly, if one patient is charged twice as much as another from the use of a particular ancillary service, it can be inferred that in the vast majority of cases, the patient who is charged twice as much consumed substantially more resources. The charge may not

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tell us the exact cost of resources used, but conclusions can be drawn about the relative costs of resources used. 2. Charges for post-discharge health services-Data regarding charges for post-discharge health services (visits by patient to the emergency room, clinic or physician’s office, or visits to patient’s home by nurses, physical therapists, home health aides, etc.) will be collected via telephone interviews with the patient at 2, 4, and 12 weeks and maintained by the patient (or proxy, if needed). Patients also will be asked to keep copies of bills received for these services. These data will be recorded on a standardized form (Appendix S). Patients will be asked to mail the record and bills 12 weeks after hospital discharge. Forms and stamped, self-addressed envelopes will be provided for this purpose prior to the patient’s hospital discharge. Copies of the patient’s bills will be returned in a timely manner. The need for postdischarge health services will be validated by a telephone interview with the patient’s attending physician and a review of the patient’s discharge plan. Data generated from the physician interview and record review will identify the use of postdischarge health services needed but not obtained as well as those not recommended as part of the discharge plan. The rationale for the use of charge data described under charges for initial hospitalization and rehospitalization applies to post-hospital health services.

Family Related Costs Data on family related costs will include patient out-of-pocket costs and costs of caring for the elderly patient at home incurred by the primary care giver. 1. Patient our-of-pocket-costs-These costs will include: costs for medications, transportation to and from post-discharge health services (i.e., physician’s offices, clinics), private nursing, health aide workers, special equipment and supplies, and miscellaneous out-of-pocket costs. Data on patient out-of-pocket costs will be collected via interviews with the patient (or proxy, if necessary). In addition, the patient will be asked to maintain a record of all out-of-pocket costs and to keep receipts for these expenses 12 weeks after discharge. Patient out-of-pocket costs will be recorded on a standardized form (Appendix T). Copies of these receipts will be returned to the patient in a timely manner. The need for out-of-pocket services will be validated by a telephone interview with the patient’s attending physician and a review of the

patient’s discharge plan. Data generated from the interview and discharge plan review will identify out-of-pocket services needed but not obtained as well as out-of-pocket expenses incurred but not recommended by the discharge plan. 2. Costs of caring for the elderly patient at home incurred by the primary care giver-These costs include the time devoted by the primary care giver to patient care; patient care related costs (transportation to and from the patient’s home, babysitting, telephone costs, etc.); and changes in the primary care giver’s pattern or type of employment. Data on time devoted to direct patient care (personal care of patient, household responsibilities) after discharge will be collected from the primary care giver via telephone interviews at 2,4, and 12 weeks; baseline data will be collected prior to the patient’s hospital discharge. These data will be recorded on a standardized form (Appendix U). Primary care givers will be asked to identify the number of hours per week that they are involved in direct patient care. The time actually spent caring for the patient will be priced out at the cost of hiring similar help in the market. Data regarding patient care-related costs and changes in the pattern and type of employment will be collected from the primary care giver via telephone interviews at 2, 4, and 12 weeks postdischarge; baseline data will be collected prior to patients’ hospital discharge. These data will be recorded on standardized data forms (Appendices V and W). Changes in the pattern or type of employment of the primary care giver includes changes in job title or hours employed per week which are associated with home care of the elderly patient. Because changes in employment resulting from home care of the elderly patient could actually have occurred prior to hospitalization, the primary care giver will be asked to report retrospectively on hidher pattern or type of employment. Changes in the number of hours per week will be the basis for analysis of changes in employment pattern. Changes in type of employment will be ascertained by asking for job titles. If changes in type of employment occur, the primary care giver will be asked if s/he perceives the change as positive or negative in terms of job advancement. The primary care giver also will be asked if changes in pattern or type of employment are related to care giving responsibilities. 3. Costs of gerontological nurse specialist services-The time that the gerontological nurse specialist devotes to the treatment proposed in this study will be recorded on a standardized form (Appendix X). All direct care, consultative, preparatory, administrative, and telephone time will


be recorded. The cost of the nurse specialist services will be calculated based on a competitive annual salary for such nurses in the Philadelphia area plus fring benefit costs. The cost of the nurse specialist time per minute will be calculated and used. This methodology was used successfully in a recent study of early hospital discharge of very low birthweight infants with nurse specialist home f o l l ~ w - u p . Based '~ on this method, it will be possible to determine the number of minutes for each patient-related action or interaction. The average cost per patient for different types of nursing interventions (i.e., assessment, teaching. consultation) also can then be calculated.

DATA ANALYSIS Frequency distributions and univariate descriptive statistics (i.e., mean, mode, and standard deviations) will be computed for every outcome variable, both overall and by each level of study variables (i.e., DRG). Through inspection of the frequency distribution, distribution anomalies (i.e., outliers, skewness) distorting the univariate summary statistics will become apparent and will be resolved either through investigation of outliers and/or variable transformation. Once the summary statistics for each outcome variable is representative of the control and treatment groups, graphics for each outcome variable by each level of these groups (i.e., DRG) at the time these variables were measured will be plotted. These visual graphs, in conjunction with the summary statistics, will maximize understanding of the impact that the comprehensive discharge planning protocol has on specific outcome, both across DRGs and at different points in time. In order to statistically assess the significance of the effects of the treatment, without capitalization on chance, multivariate analyses will be conducted. Specifically a 2 X 4 multivariate analysis of variance (MANOVA) [one factor is group assignment with two levels (control and treatment); the other is the four DRG categories] and a discriminant analysis will be computed separately for each set of outcome variables (i.e., patient, family related, and cost of care outcomes). The MANOVA will test for significant group differences (main effect and interaction) on all interval level outcome variables within a set, while the discriminant analysis will indicate to what extent variables in the set are more or less associated with type of discharge planning treatment (control versus treatment group).

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Prior to conducting the multivariate analyses, assumptions underlying the statistical treatment will be tested, and any violation will be corrected. Also, intercorrelations among a set of outcome variables will be obtained to minimize multicollinearity, understand the interrelatedness among a set of common outcome variables, and use nonrelated variables in the multivariate analyses. Any variables correlating more than r = .60 with other variables will be combined into one composite variable. Univariate post hoc comparisons (i.e., Tukey) will only be computed for those interval level outcome variables with a significant interaction effect and/or significant DRG effect on the multivariate analyses. The significance of the control versus treatment group effects on nominal level outcome variables will be assessed with Chi-square. To examine the consistency of the effects of control versus treatment across time the same analyses will be computed at other points in time after hospital discharge. All univariate descriptive statistics will be computed on the microcomputer using the SPSS PC+ statistical package; all multivariate analyses will be computed on the DEC/ VAX 8600 mainframe using SPSS-X and SAS.

HUMAN SUBJECTS The sample will consist of 280 hospitalized elderly, both men and women who are 70 years or older, admitted to medical or surgical units (excluding intensive care units) at the Hospital of the University of Pennsylvania (HUP) with the primary DRG classification of simple pneumonia or pleurisy (DRG 89); congestive heart failure (DRG 127); hip fracture (DRG's 209, 210); and cardiac surgical disorders (DRG's 104, 105, 106, 107, 108, 117, and 118). Patients from all socioeconomic levels who are alert and oriented at admission; speak English and able to respond to questions; admitted from home, since these patients are more likely to be discharged home; and able to be reached by telephone post-discharge will be eligible for the study. Family related members also will be included in this study. For the purpose of this study, the primary care giver is a family related member who primarily will be responsible for the care of the patient in the home after hospital discharge. Patients will be solicited within 24 hours of admission by a project manager and followed by a gerontological clinical specialist for 2 weeks post-hospital discharge. However, data collection to evaluate outcomes of patients and primary care

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givers will be extended to 3 months post-hospital discharge. When eligible subjects have been identified, the manager will meet with the patient, explain the study’s purpose, and obtain consent. For the patients who have difficulty seeing or hearing, the manager will arrange to have the hospital’s patient advocate available during the process of obtaining consent. For patients who have a primary care giver the project manager will schedule a meeting to explain the family related component of this study and obtain consent. Following informed consent, subjects will be randomly assigned to control or treatment group. The patients in the control group will receive the general discharge plan used for all categories of patients at HUP. The patients in this group will be asked to complete six questionnaires five times during the 3 months following hospital discharge. In addition, the patients will be interviewed post-hospital discharge to obtain information regarding infection and rehospitalization. The questionnaires will take between 45 and 60 minutes to complete at any data point, and will be mailed to them with a stamped return envelope. Interviews will be conducted at the convenience of the patient. The primary care giver will complete five questionnaires during the patient’s 3-month follow-up. The questionnaires will take between 30 to 45 minutes to complete at any data point, and will be mailed to them with a stamped return envelope. A $30 gratuity will be paid, $15 to the patient and $15 for the primary care giver. The patients in the treatment group will receive all components of HUP’s general discharge planning procedure. In addition, this group also will receive the services of a gerontological nurse specialist who will implement a comprehensive discharge planning protocol developed specifically for the elderly. The gerontological clinical specialist will see all subjects at least four times during their initial hospitalization: within 24 hours of admission, a minimum of two visits during the patient’s hospitalization and within 24 hours prior to hospital discharge to evaluate and make modifications in the discharge plan. She will provide each patient and primary care giver with a 2-hour per day, 7day per week schedule of telephone availability during the patient’s hospitalization and for 2 weeks post-discharge. The nurse specialist will initiate a minimum of two telephone calls during the first 2 weeks after discharge to monitor adaptation of the patient and primary care giver to home. The first telephone call will be made between 24 and 48 hours after discharge. A second telephone call will be made at approximately 1 week post-hospital discharge. Patients and primary care givers in this

group will also be asked to complete the same questionnaires and patient interviews regarding the same morbidity data as patients in the control group. All subjects will be informed that the information they provide during the study will be kept confidential and used only for purposes of statistical analysis. They will be assured that their decision to participate or not in the research will in no way affect their status or care in the institution. They will be informed that they may withdraw from the study at any time. The potential subject will be encouraged to ask questions and given time to consider hidher decision and confer with family members, if needed. Written consent will be obtained (Appendix B). The questionnaires and interviews should not cause stress or anxiety for subjects. Appropriate medical and nursing management is available to the subjects in the event of adverse effects. At times other than scheduled telephone calls, should immediate care be needed, subjects are asked to telephone their physician, or the hospital emergency room at the Hospital of the University of Pennsylvania. There are no potential legal or social risks for patients who participate. Confidentiality will be safeguarded through coding mechanisms. Names of patients will be removed from the data and a code assigned. Each subject’s identifying data will be separated from the study data. The key identifying code numbers with subjects’ names will be kept by the principal investigator in a locked file and all identifying information will be destroyed at the earliest possible time following collection. All data will be analyzed by groups with no ability to identify individual patients. Any publications arising from this study will not contain any personal identifying information.

Potential Benefits This study will provide new information about the patient outcomes, family-related outcomes, and cost of care outcomes related to discharge planning of the elderly. Collection of study data should help health care providers assess a more effective and efficient hospital discharge planning process and the potential to facilitate the transition of the elderly from hospital to home, nursing home, and life care communities. Individual benefits may accrue to experimental subjects through their consistent contact with a nurse specialist and through comprehensive discharge planning protocol.


Potential Risks There are no known medical, legal or social risks for patients or primary care givers w h o participate in this study.

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SUMMARY STATEMENT NURSING RESEARCH STUDY SECTION Resume Approval is recommended for this study in which attempts are made to answer a number of questions regarding discharge planning for hospitalized elderly with selected DRG classifications. Strength can be found in every aspect of the study, from conceptualization to operationalization, design, protocols, and the research team. A caution is related to the sensitivity of some of the measures for use with the elderly, yet that is where the technology is at present.

Description (Editor’s note: This section was adapted from the investigator’s abstract and, to conserve space, is omitted here.)

Critique Conceptually and methodologically, this is a strong proposal which is superbly written. The ideas are presented clearly and convincingly, and the detail to technical and methodological aspects shows the extreme care with which this study was designed. Coupled with the strength of the research team and the ongoing work related to comprehensive and early discharge planning at the applicant institution, this study promises to make contributions that could significantly affect 40% of the consumers of tertiary health care services. The specific aim is straightforward and refreshing in its lucidity.


The outcomes of interest are relevant to the target population and, with regard to the cost of care outcomes, to the health services being investigated. The significance section is excellent. In it are reviewed the framework, the larger context or background, aspects of discharge planning, and the utilization of nurse specialists. It is written clearly, rationally, and convincingly. Even though the principal investigator has not had much prior research experience in this area, her background and work to date, together with the related work by Brooten and her associates, provide a sound argument in favor of this proposed research. The attention to technical and methodological aspects is exemplary. The design is a straightforward randomized trial design. The independent variable is conceptualized well and operationalized superbly. In general, the quality of conceptualization and operationalization of variables is superb. The procedures for sample selection are equally well described. The argument to limit this study to two medical and two surgical diagnoses brings to the study a sample homogeneity that is neither too strict nor too loose. Given that this is an initial study in the area, this nice balance between strictness and looseness promises to yield useful data. Feasibility information is included, which allows verification of the ability to enroll the requisite number of subjects. The statistical power analysis was done appropriately. The description of the procedure and the protocols is done in such detail that replicability is assured. It also allows one to infer the feasibility of the protocols beyond the study, which in turn allows one to conclude that the experimental protocol, if upheld to be superior, can be adopted by investigators in the field. The

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dependent measures are described in detail. While some of the selected measures have not always been helpful in research with the elderly, a sound argument against their use cannot be made. At most, perhaps this should be a note of caution to the investigators. The conceptualization and operationalization of cost of care outcomes are appropriate. The investigator is encouraged to consider observational checks to validate the gerontological nurse specialist self-report records and selected home interviews to evaluate patient and caregiver cost self-report records.

Investigators Although the principal investigator, M. Naylor, R.N., Ph.D., is a relatively junior researcher, the strength of the research team as a whole is most impressive. This project can be implemented without major problems.

Resources and Environment The resources and environment at the applicant institution, including its hospital are excellent. Most notable also is that this project will undoubtedly be integrated into the work already on the way at that institution under the leadership of Brooten.

Budget The budget is appropriate and no changes are recommended.

Planning for effective hospital discharge.

Discharge planning.

Discharge planning.

The anatomy of discharge planning.

Evaluating social work discharge planning services for elderly people: access, complexity, and outcome.

Reinforcing discharge education and planning.

Delays in the discharge of elderly patients.

Implementing a multidisciplinary approach to discharge planning.

Will enhanced planning for the elderly reduce hospital visits?

Impediments to the course and effectiveness of discharge planning.

Academic preparation for professionals engaged in comprehensive health planning.

Development of a discharge readiness report within the electronic health record-A discharge planning tool.

Discharge planning and home care in the United States.

DRGs and the social worker's role in discharge planning.

Enhancing patient participation: clinical strategies in the discharge planning process.

A comprehensive formulation for volumetric modulated arc therapy planning.

Evaluation: A keystone of Comprehensive Health Planning.

State level comprehensive health planning: a retrospect.

Communication of discharge information for elderly patients in hospital.

Can the Blaylock Risk Assessment Screening Score (BRASS) predict length of hospital stay and need for comprehensive discharge planning for patients following hip and knee replacement surgery? Predicting arthroplasty planning and stay using the BRASS.

Admission and discharge of frail elderly people.

Transition to home: discharge planning for the oxygen-dependent infant with bronchopulmonary dysplasia.

Investigating hyponatremia, exit-site management and discharge planning.

Discharge planning in chronic conditions: an evidence-based analysis.