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Discharge Planning

Introduction

Long-term conditions are referred to as conditions, which cannot be cured within the existing clinical and medicinal practices, but these conditions can be managed by the use of appropriate therapies and medications (Fletcher, 2019). An integrated care team is mainly required for managing the care of patients with long term conditions so as to help them improve their health outcomes (Bower et al., 2018). With changes in the age and lifestyle of people, it is important for the health systems to take into consideration the substantial prevalence of long term conditions among people. It has been noted by the Royal College of Nursing that nursing expertise is substantially required to prevent emerging challenges which include increased prevalence of long-term conditions and thus, complex nursing care is required for prevention and management (Wilson, 2019). For the appropriate management of people experiencing long-term conditions, district or community nurses are considered as essential figures in delivering a set of complex and diverse skills for supporting the health agenda during the management of such people (Cramm and Nieboer, 2017). Besides, appropriate psychosocial and physical assessment along with holistic objective is one of the vital approaches for constructing a trustworthy relationship with patients dealing with long-term conditions. However, this approach significantly requires accurate signposting of patients to a most vital source of information and interdisciplinary teamwork in order to provide assistance to the patient for making appropriate choices and promoting self-care (Chan et al., 2018).  

Discharge planning for patients who require long-term care to manage chronic diseases is one of the most challenging tasks since it requires the transition of patients from hospital to self-care (Coyne et al., 2019). The current assignment, however, focuses on discharge planning for a 31-year old man who had been diagnosed with several immunological abnormalities and acquired antiretroviral therapy (ART). He was also found to have developed syphilis due to several sexual contacts in Mali, and now after treatment, he has been ready for the discharge to be planned although it had been found that his daughter and wife had developed HIV infection. The major aim of this assignment is to discuss strategies for supporting and empowering the patient living with long-term conditions and their significant others when planning their discharge from the hospital.

Discussion

The influence of several morbidities has observed to be profound. People who have been dealing with multiple long-term conditions are found to pose poorer clinical outcomes, longer hospital stays and poorer quality of life (Anderson and Ozakinci, 2018). Other than this, they are considered to be one of the most expensive or challenging patients that the NHS has to look after. Previous pieces of evidence have suggested quality care for patients experiencing several long-term conditions as well as certain quality measures which are required for managing conditions. It has been evident that several long-term conditions acquire poorer management due to general practices being served within the healthcare (Kidd et al., 2017). This requires more collaborative teamwork since such patients need systematic management, which would help in maintaining their mental as well as physical stability. Thus, appropriate care model is generally required to be integrated successfully for the management of such patients and which comprises of multidisciplinary care management and follow-up (Struckmann et al., 2018).

However, for managing multi-morbidity of a 31-year old Dillon Hunt, it is important for the general practitioners along with other significant healthcare professionals to play lead role, therefore, they must work in collaboration to each other in order to assess each condition of patient accurately. Based on the nature or severity of each condition, they must plan quality care for him. Other than this, the patient’s preference would also need to be integrated into the care plan. The professionals would need to contact the family of Dillon in order to discuss his behaviour and other practices at home and outside. The patient had been on medications; therefore, follow-ups would be required in order to assess whether the patient is in the condition to acquire treatment at home or not.

Discharge Plan

A discharge plan is defined as an interdisciplinary approach for the continuity of care management for patients with long-term conditions. This process, however, comprises of elements which include identification, assessment, goal setting, planning, execution, coordination and analysis (Facchinetti et al., 2019). It requires a link between community-based services, hospitals, carers as well as a non-government organisation. The discharge planning is based on the needs of the patient, and efficient discharge planning encourages the management of quality care between the community and healthcare setting. The main purpose of the discharge planning is to minimise the duration of the hospital stay, to improve the administration of services after discharge from healthcare centre and to also reduce frequent readmission to the hospital (Gonçalves‐Bradley et al., 2016). Following is the discharge plan which has been planned out for Dillon although, he has not been treated completely.

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Type of Discharge

In Dillon’s scenario, the discharge will be complex. This is because he has been diagnosed with several LTCs. Also, he has been suspected of having developed sexually transmitted disease, which might be either syphilis or HIV. He has not received complete treatment; therefore, his discharge would be complex, which comprises of certain other post-discharge therapies.

 

 

 

Factors

Expected date of discharge.

It is important for the healthcare professionals to check living arrangements for the patient, such as the surrounding of the home, health conditions of the patient’s family and the assistance required by the patient.

Expectations for the recovery and the time period required for the recovery to be completed.

The ability of the patient to deal and overcome with the situation at home considering the needs of the carer and the treatment required by the patient that is either he needs to go to nursing care or require community assistance including cleaning and medication.

Any limitations or restrictions on the activities of the patient, including driving, lifting etc.

Assessing equipment which might provide assistance in treating Dillon’s condition.

 

Medication or Intervention

 

The medicines which have been prescribed by GPs in the hospital would need to be continued so as to prevent the patient from more adverse health-related outcomes. The patient requires other therapeutic intervention as well in order to treat syphilis and HIV and prevent him from acquiring other chronic diseases.

 

Diet

 

Appropriate diet is required, which include fruits and vegetables along with lean protein. Such a diet would provide assistance in building a strong immune system.

 

MDT Team

 

Community nurses, allied health staff or care taker are required for managing Dillon’s condition along with his partner and daughter’s chronic illness. A general practitioner will be assigned for the regular follow-ups in hospital in order to assess the condition of Dillon.


This specific discharge plan has been outlined with reference to certain supporting pieces of evidence which have significantly emphasised on the importance of discharge plan specifically for patients with long-term conditions. It has been argued by Manias et al. (2019) that more than 40% of the patients aged between 50-75 years old, with long-term conditions, mainly shows errors related to appropriate medication after being discharged from hospital. While 20% of the patients in Medicare are observed to seek readmission within 30 days after being discharged, however, it has been claimed by several other scholars such as Yiadom et al. (2018) that efficient planning along with effective follow-up provides assistance in improving health outcomes of a patient, minimise healthcare expenses and decrease the frequency of readmissions. Among multiple factors, emotional factor is considered as the most significant in developing communication between the patient and care providers. This further helps in planning much appropriate care management for the patients.

Family involvement in the Discharge Process

It is important to involve family members and more often patients in the discharge process at the initial phases. This is because of the reason that family members help in informing the multidisciplinary team regarding the cultural and moral values of the patient (Oyesanya, 2017). Other than this, the patient’s preference in planning discharge is also significant in order to understand what type of care is required by the patient and his/her other basic needs. As per NICE guidelines, it is essential to take into consideration the moral as well as ethical values of the patient (Rumbold et al., 2017). In case of Dillon, his partner would be contacted so as to acquire information about his finances, disability which she and their daughter have been going through as well as the living conditions which might influence on the health outcomes of the patient. Based on the needs of the patient and information revealed by Dillon’s family, the discharge plan can get modified.

It is, therefore, essential to provide education and information to patient’s caregivers on healthcare. Preceding with the discharge plan for Dillon, his family has been integrated into the multidisciplinary meetings or conferences in order to assess the concerns of his family regarding the discharge plan. By involving, family members or caregivers in such conferences build trust among healthcare team members. Other than this, it is important to educate the family about the application of necessary equipment and the consequences of the interventions utilised so as to help them cope with such circumstances (Seaman et al., 2017).

Communication Strategies in Discharge Planning

One of the essential factors for successful discharge planning is the development of efficient communication between the patient and healthcare practitioners (Gholizadeh et al., 2016). This communication however, depends on the open dialogue on which a common vision is being shared. Several scholars have emphasised on the significance of efficient communication in discharge planning. For instance, Crispin, Bugge and Stoddart (2017) conducted an influential qualitative study in which semi-structured interviews have been used for assessing the significance of effective communication between patient and healthcare professionals. The findings of this study, however, indicated that during discharge planning the process of ‘asking questions’ is a key component. This is because of the reason that this process significantly helps in acquiring sufficient information about a patient’s health-related issues.

Furthermore, it has been reported by Dean et al. (2016) that the two new significant tools must be incorporated when planning discharge, namely, admission and discharge journal, and multidisciplinary record. The study proposed by Naylor et al. (2017) has also considerably focused on the role of communication. However, it has been further argued that communication is one of the most appropriate components required for efficient hospital discharge. In accordance with the staff of healthcare centres, it has been evaluated that open discussion and communication from initial stages is beneficial in the process of the discharge as it helps in better understanding of the patient’s condition and needs.

With reference to the case of Dillon, the communication has included the interaction between community team members about the arrangements for the patient’s appointment and interacting with the district nurse. This communication might help in planning appropriate care management for Dillon as well as his family. Valente et al. (2020) argued that inadequate communication, however, leads to several problems related to the administration of medicines and thus, increases the chances of readmission. Since Dillon has not received complete treatment in the hospital, it might be possible for him to visit the hospital again after discharge in order to control pain and manage manifestations of identified illnesses.

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Conclusion

From the above discussion, it can be concluded that discharge planning for patients with long-term conditions is one of the most complex or challenging processes. This is because of the fact that patients with LTC require quality care since such diseases are incurable and so care management could only provide assistance in preventing such patients from dealing with more adverse situations. Therefore, efficient multidisciplinary team is required who would help in managing quality care for such patients.


 

References

Anderson, N. and Ozakinci, G., 2018. Effectiveness of psychological interventions to improve quality of life in people with long-term conditions: rapid systematic review of randomised controlled trials. BMC psychology, 6(1), p.11.

Bower, P., David, R., Sutton, M., Lovell, K., Blakemore, A., Hann, M., Howells, K., Meacock, R., Munford, L., Panagioti, M. and Parkinson, B., 2018. Improving care for older people with long-term conditions and social care needs in Salford: the classic mixed-methods study, including RCT. Health Services and Delivery Research.

Chan, E.A., Wong, F., Cheung, M.Y. and Lam, W., 2018. Patients' perceptions of their experiences with nurse-patient communication in oncology settings: A focused ethnographic study. PloS one, 13(6).

Coyne, I., Sheehan, A., Heery, E. and While, A.E., 2019. Healthcare transition for adolescents and young adults with long‐term conditions: Qualitative study of patients, parents and healthcare professionals’ experiences. Journal of clinical nursing, 28(21-22), pp.4062-4076.

Cramm, J.M. and Nieboer, A.P., 2017. Self‐management abilities and quality of life among frail community‐dwelling individuals: the role of community nurses in the Netherlands. Health & social care in the community, 25(2), pp.394-401.

Crispin, V., Bugge, C. and Stoddart, K., 2017. Sufficiency and relevance of information for inpatients in general ward settings: A qualitative exploration of information exchange between patients and nurses. International journal of nursing studies, 75, pp.112-122.

Dean, S.M., Gilmore-Bykovskyi, A., Buchanan, J., Ehlenfeldt, B. and Kind, A.J., 2016. Design and hospitalwide implementation of a standardized discharge summary in an electronic health record. The Joint Commission Journal on Quality and Patient Safety, 42(12), pp.555-AP11.

Facchinetti, G., D’Angelo, D., Piredda, M., Petitti, T., Matarese, M., Oliveti, A. and De Marinis, M.G., 2019. Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: a meta-analysis. International journal of nursing studies, p.103396.

Fletcher, G.S., 2019. Clinical epidemiology: the essentials. Lippincott Williams & Wilkins.

Gholizadeh, M., Delgoshaei, B., Gorji, H.A., Torani, S. and Janati, A., 2016. Challenges in patient discharge planning in the health system of Iran: A qualitative study. Global journal of health science, 8(6), p.168.

Gonçalves‐Bradley, D.C., Lannin, N.A., Clemson, L.M., Cameron, I.D. and Shepperd, S., 2016. Discharge planning from hospital. Cochrane database of systematic reviews, (1).

Kidd, T., Carey, N., Mold, F., Westwood, S., Miklaucich, M., Konstantara, E., Sterr, A. and Cooke, D., 2017. A systematic review of the effectiveness of self-management interventions in people with multiple sclerosis at improving depression, anxiety and quality of life. PloS one, 12(10).

Manias, E., Bucknall, T., Hughes, C., Jorm, C. and Woodward-Kron, R., 2019. Family involvement in managing medications of older patients across transitions of care: a systematic review. BMC geriatrics, 19(1), p.95.

Naylor, M.D., Shaid, E.C., Carpenter, D., Gass, B., Levine, C., Li, J., Malley, A., McCauley, K., Nguyen, H.Q., Watson, H. and Brock, J., 2017. Components of comprehensive and effective transitional care. Journal of the American Geriatrics Society, 65(6), pp.1119-1125.

Oyesanya, T., 2017. The experience of patients with ABI and their families during the hospital stay: a systematic review of qualitative literature. Brain injury, 31(2), pp.151-173.

Rumbold, B., Weale, A., Rid, A., Wilson, J. and Littlejohns, P., 2017. Public reasoning and health-care priority setting: The case of NICE. Kennedy Institute of Ethics Journal, 27(1), p.107.

Seaman, J.B., Arnold, R.M., Scheunemann, L.P. and White, D.B., 2017. An integrated framework for effective and efficient communication with families in the adult intensive care unit. Annals of the American Thoracic Society, 14(6), pp.1015-1020.

Struckmann, V., Leijten, F.R., van Ginneken, E., Kraus, M., Reiss, M., Spranger, A., Boland, M.R., Czypionka, T., Busse, R. and Rutten-van Mölken, M., 2018. Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review. Health Policy, 122(1), pp.23-35.

Valente, J., Johnson, N., Edu, U. and Karliner, L.S., 2020. Importance of Communication and Relationships: Addressing Disparities in Hospitalizations for African-American Patients in Academic Primary Care. Journal of general internal medicine, 35(1), pp.228-236.

Wilson, C., 2019. Improved access to health care and self-management of long-term and disabling conditions including end-of-life care: a corpus of published work incorporating evidence appraisals and critical approaches to public health (Doctoral dissertation, University of Cumbria (awarding body Lancaster University).

Yiadom, M.Y.A., Domenico, H., Byrne, D., Hasselblad, M.M., Gatto, C.L., Kripalani, S., Choma, N., Tucker, S., Wang, L., Bhatia, M.C. and Morrison, J., 2018. Randomised controlled pragmatic clinical trial evaluating the effectiveness of a discharge follow-up phone call on 30-day hospital readmissions: balancing pragmatic and explanatory design considerations. BMJ open, 8(2), p.e019600.

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