Hospital Discharge

8.3 Continuity of care
Poor communication coupled with a lack of
involvement in discharge planning led patients to
experience uncoordinated care, both during their
hospital stay and once home (transitional care).
These problems sometimes resulted in raised
anxiety among patients (and their carers) before
leaving hospital and further, in patients’ being
readmitted to hospital soon after discharge. Many
participants reported that, though they were told
that they were ready to be discharged, health
care staff provided them with little information
about the status/progression of their illness, the
treatments for their illness, and the impact of
both on their daily activities. These participants
commented on the fact that as soon as they
were deemed to be ready for discharge, the
health care staff’s main focus was carrying it out
quickly, rather than spending time with them and
explaining what would happen next. As a result,
these participants reported that they left the
hospital with a partial or limited understanding
of the impact of their illness and medication
on their daily activities once discharged. A
few patients revealed how the fragmented
interface between secondary and primary care
services contributed to them experiencing their
transitional care as uncoordinated.
Patients who reported being involved in planning
their discharge and transitional care described
their care as coordinated. In contrast, participants
who reported that they were uninvolved in
planning their discharge described these
processes as uncoordinated.
8.4 Staff and resource issues
Communication problems were exasperated
by other issues such as staff shortages, and
additional resource issues relating to care
packages. Staff were largely highly praised
by patients but our data revealed that staff
shortages resulted in staff feeling under pressure,
at times, to discharge patients too quickly,
while simultaneously experiencing a backlog
of assessments meaning that patients were
unnecessarily delayed. Tensions between the
social and health care teams were reported.
Participants working within the social care team
reported that they were unfairly criticised for
delayed discharges by the senior management
team, family members and their health care
colleagues. A combination of the small size of
the team and their already high caseloads, which
were further increased as they had to source
care for deferred patients, resulted in delayed
discharges. Many patients, despite their complex
needs, ended up receiving care packages that
did not meet their needs adequately and others
preferred to be discharged with no or limited
care provision in the community, rather than
wait until their assessments were carried out and
their care packages were sourced from either the
health or social care authorities. Both outcomes
had a negative impact on patients’ experience
of discharge and hospital staffs’ experience of
discharge planning.
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