Improving hospital discharge planning for elderly patients

Health Care Financing Review

Volumn 19, Issue 2, 1997, Pages 47-72

  Potthoff, Sandra ^b   Kane, Robert L ^c   Franco, Sheila J ^a  

^a Project Hope   (United States)

^b UNIVERSITY OF MINNESOTA   (United States)

^c NONE

Author keywords

[No Author keywords available]

Indexed keywords

GERIATRIC PATIENT; HEALTH CARE PLANNING; HOME CARE; HOSPITAL DISCHARGE; LONG TERM CARE; MANAGED CARE; MEDICAL DECISION MAKING; MEDICARE; NURSING HOME; OUTPATIENT CARE; REVIEW; SELF CARE;

ACTIVITIES OF DAILY LIVING; AGED; CONTRACT SERVICES; DECISION MAKING, ORGANIZATIONAL; GERIATRIC ASSESSMENT; HEALTH SERVICES RESEARCH; HOME CARE SERVICES; HUMANS; NURSING HOMES; OUTCOME ASSESSMENT (HEALTH CARE); PATIENT DISCHARGE; QUALITY ASSURANCE, HEALTH CARE; RECOVERY OF FUNCTION;

EID: 0031350036     PISSN: 01958631     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (105)

1. Abrahams, R., Capitman, J., Leutz, W., et al.: Variations in Care Planning Practice in the Social/HMO: An exploratory study. Gerontologist 29(6):725-736, 1989.
2. Abramson, J.S.: Enhancing Patient Participation: Clinical Strategies in the Discharge Planning Process. Social Work in Health Care 14(4):53-71, 1990.
3. Abramson, J.S., Donnelly, J., King, M.A., and Mailick, M.D.: Disagreements in Discharge Planning: A Normative Phenomenon. Health and Social Work 18:57-64, 1993.
4. Argyris, C.: Single-Loop and Double-Loop Models in Research on Decisionmaking. Administrative Science Quarterly 21:363-375, 1976.
5. Bass, R.D.: A Method for Measuring Continuity of Care in a Community Mental Health Center. Rockville, MD.: Department of HEW, 1978.
6. Bjorkman, M.: Feedforward and Feedback as Determiners of Knowledge and Policy Notes on a Neglected Issue. Scandinavian Journal of Psychology 13:152-158, 1972.
7. Blazyk, S., and Canavan, M.M.: Managing the Discharge Crisis Following Catastrophic Illness or Injury. Social Work in Health Care 11(4):19-32, 1986.
8. Blewett, L.A., Kane, R.L., and Finch, M.: Hospital Ownership of Post-Acute Care and Use of Post-Acute Care Services. Inquiry 32(4):457-467, 1996.
9. Blumenfield, S., and Rosenberg, G.: Towards a Network of Social Health Services: Redefining Discharge Planning and Expanding the Social Work Domain. Social Work in Health Care 13:(31-48), 1988.
10. Boyle, K., Nancy, J., and Passau-Buck, S.: Post-Hospitalization Concerns of Medical-Surgical Patients. Applied Nursing Research 5:122-126, 1992.
11. Brehmer, B.: Dynamic Decisionmaking: Human Control of Complex Systems. Acta Psychologica 81:211-241, 1992.
12. Cornelius, E.S., and Friedlob, A.S.: Interstate Variation in Medicare Skilled Nursing Facility Residents Characteristics. Office of Demonstrations and Evaluations, Health Care Financing Administration. Baltimore, MD. 1986.
13. Coulton, C.J.: (1988). Prospective Payment Requires Increased Attention to Quality of Post Hospital Care. Social Work in Health Care 13(4):19-30, 1988.
14. Coulton, C.J.: Research in Patient and Family Decisionmaking Regarding Life Sustaining and Long-Term Care. Social Work in Health Care 15(1):63-78, 1990.
15. Coulton, C.J., Dunkle, R.E., Chow, J.C., et al.: Locus of Control and Decisionmaking for Posthospital Care. The Gerontologist 29(5):627-632, 1989.
16. Coulton, C.J., Dunkle, R.E., Chun-Chun, J., et al.: Dimensions of Post-Hospital Care Decisionmaking: A Factor Analytic Study. The Gerontologist 28(2):218-223, 1988.
17. Coulton, C.J., Dunkle, R.E., Goode, R.A., et al.: Discharge Planning as a Decisionmaking Process. Health and Social Work 7:253-261, 1982.
18. Dawes, R.M., Faust, D., and Meehl, P.E.: Clinical Versus Actuarial Judgment. Science 243:1668-1673, 1989.
19. DesHarnais, S., Cheney, J., and Fleming, S.: Trends and Regional Variations in Hospital Utilization and Quality During the First Two years of the Prospective Payment System. Inquiry 25:374-382, 1988.
20. Dunkle, R.E., Coulton, C.J., Goode, R.A., et al.: Factors Affecting the Post-Hospital Care Planning of Elderly Patients in an Acute Care Setting. Journal of Gerontological Social Work 4:95-106, 1982.
21. Einstadter, D., Cebul, R.D., and Franta, P.R.: Effect of a Nurse Case Manager on Postdischarge Follow-up. Journal of General Internal Medicine 11(11):684-688, 1996.
22. Findeisen, W., and Quade, E.S.: The Methodology of Systems Analysis: An Introduction and Overview. In Miser, H.J., ed.: Handbook of Systems Analysis: Overview of Uses, Procedures, Applications, and Practice. New York: Elsevier Publishing Company, 1985.
23. Fox, K.M., Hawkes, W.G., Hebel, J.R., et al.: Mobility After Hip Fracture Predicts Health Outcome. Journal of the American Geriatrics Society 46:169-173, 1998.
24. Gornick, M., and Hall, M.J.: Trends in Medicare Utilization of SNFs, HHAs, and Rehabilitation Hospitals. Health Care Financing Review, Annual Supplement: 27-38, 1988.
25. Greenberg, S.: Computer-Supported Cooperative Work and Groupware. London: Harcourt Brace Jovanovich, 1991.
26. Gustafson, D.H., Bosworth, K., Hawkins, R.P., et al.: CHESS: A Computer-Based System for Providing Information, Referrals, Decision Support and Social Support to People Facing Medical and Other Health-Related Crises. Paper presented at the Proceedings of the Annual Symposium on Computer Application in Medical Care. 1992.
27. Gustafson, D.H., Cats-Baril, W.L., and Alemi, F: Systems to Support Health Policy Analysis, Theory, Models, and Uses. Ann Arbor, MI: Health Administration Press, 1992.
28. Guterman, S., and Dobson, A.: Impact of the Medicare Prospective Payment System for Hospitals. Health Care Financing Review 7(3):97-114, 1986.
29. Hammond, K.R., and Adelman, L.: Science, Values, and Human Judgment. Science 194:389-396, 1976.
30. Hammond, K.R., McClelland, G.H., and Mumpower, J.: Human Judgment and Decision Making: Theories, Methods, and Procedures. New York: Praeger, 1980.
31. Hartigan, E.G., and Brown, J.B.: Discharge Planning for Continuity of Care. New York: National League of Nursing, 1985.
32. Health Care Financing Administration: Report of the Secretary's Advisory Panel on the Development of Uniform Needs Assessment Instrument (s). Washington, DC.: US Government Printing Office, 1992.
33. Hennessy, C.H.: Modeling Case Management Decisionmaking in a Consolidated Long-Term Care Program. The Gerontologist 33:333-341, 1993.
34. Hoffman, F.M.: Diagnosis-Related Groups: Fears and Realities. In McClelland, E., Kelly, K., and Buckwalter, K.C., eds.: Continuity of Care: Advancing the Concept of Discharge Planning. Orlando, FL: Grune and Stratton, 1985.
35. Holtzman, J., Chen, Q., and Kane, R.L.: The Effect ogf HMO Status on the Outcomes of Home Care Following Hospitalization in a Medicare Population. Journal of the American Geriatrics Society, to be published.
36. Jackson, M.E., Eichorn, A., Sokoloff, S., et al.: Evaluating the Predictive Validity of Nursing Home Pre-Admission Screens. Health Care Financing Review 14(4):169-180, 1993.
37. Janis, I.L., and Mann, L: Decision Making, A Psychological Analysis of Conflict, Choice, and Commitment. New York: Free Press, 1977.
38. Jewell, S.E.: Discovery of the discharge process: A Study of Patient Discharge From a Care Unit for Elderly People. Journal of Advanced Nursing 18:1288-1296, 1993.
39. Kadushin, G., and Kulys, R.: Discharge Planning Revisited: What Do Social Workers Actually Do in Discharge Planning? Social Work 38:713-726, 1993.
40. Kahn, K.L., Keeler, E.B., Sherwood, M.J., et al.: Comparing Outcomes of Care Before and After Implementation of the DRG-Based Prospective Payment System. Journal of the American Medical Association 264(15):1984-1988, 1990.
41. Kane, R.A.: (1985). Decisionmaking, Care Plans, and Life Plans in Long-Term Care: Can Case Managers Take Account of Client's Values and Preferences. In McCullough, L.B., and Wilson, N.L., eds.: Long Term Care Decisions: Ethical and Conceptual Dimensions. Baltimore: Johns Hopkins University Press, 1985.
42. Kane, R.A., and Kane, R.L.: Assessing the Elderly: A Practical Guide to Measurement. Lexington, MA: D.C. Heath, 1981.
43. Kane, R.L.: The Implications of Assessment. The Journal of Gerontology 48 (Special Issue):27-31, 1993.
44. Kane, R.L.: A Study of Post-Acute Care: Final Report. (HCFA #17-C98891). Minneapolis, MN: Institute for Health Services Research, University of Minnesota School of Public Health, 1994.
45. Kane, R.L., Chen, Q., Finch, M., et al.: Functional Outcomes of Post-Hospital Care for Stroke and Hip Fracture Patients Under Medicare. Journal of the American Geriatrics Society, to be published (a).
46. Kane, R.L., Chen, Q., Finch, M., et al.: The Optimal Outcomes of Post-Hospital Care Under Medicare. Health Services Research, to be published (b).
47. Kane, R.L., Feldman, R., Finch, M., et al.: Issues in Bundling Hospital and Post-Acute Care. Final report (HCFA 99-C-99169/05-0255). Minneapolis, MN: Division of Health Services Research and Policy, University of Minnesota School of Public Health, 1993.
48. Kane, R.L., Finch, M., Blewett, L., et al.: Use of Post-Hospital Care by Medicare Patients. Journal of the American Geriatrics Society 44:242-250, 1996.
49. Kasper, J.F., Mulley, A.G., and Wennberg, J.E.: Developing Shared Decisionmaking Programs to Improve the Quality of Health Care. Quality Review Bulletin 18(6):183-190, 1992.
50. Kiel, D.P., Eichorn, A., Intrator, et al.: The Outcomes of Patients Newly Admitted to Nursing Homes After Hip Fracture. American Journal of Public Health 84(8):1281-1286, 1994.
51. Kilgore, K.M.: Measuring Outcomes in the Post-Acute Continuum. Archives of Physical Medicine and Rehabilitation 76(12 Suppl):SC21-SC26, 1995.
52. Kitto, J., and Dale, B.: Designing a Brief Discharge Planning Screen. Nursing Management 16:28-30, 1985.
53. Koopman, P., and Pool, J.: Organizational Decisionmaking: Models, Contingencies, and Strategies. In Rasmusse, J., Brehmer, B., and Leplat, J., eds.: Distributed Decision Making: Cognitive Models for Cooperative Work. West Sussex, England: John Wiley & Sons, Ltd., 1991.
54. Kosecoff, J., Kahn, K.L., Rogers, W.H., et al.: Prospective Payment System and Impairment at Discharge: The 'Quicker and Sicker' Story Revisited. Journal of the American Medical Association 264:1980-1983, 1990.
55. Kruse, K.A.: Analysis of Roles in Discharge Planning. In McClelland, E., Kelly, K., and Buckwalter, K.C., eds.: Continuity of Care: Advancing the Concept of Discharge. Orlando, FL: Grune & Stratton, Inc., 1985.
56. Liu, K., McBride, T., and Coughlin, T.: Risk of Entering Nursing Homes for Long Versus Short Stays. Medical Care 32:315-327, 1994.
57. Lockery, S., Dunkle, R., Kart, C., et al.: Factors Contributing to the Early Rehospitalization of Elderly People. Health and Social Work 19(3):182-191, 1994.
58. MacNeill, S.E., and Lichtenberg, PA: Home Alone: The Role of Cognition in Return to Independent Living. Archives of Physical Medicine and Rehabilitation 78:755-758, 1997.
59. Mamon, J., Steinwachs, D.M., Fahey, M., et al.: Impact of Hospital Discharge Planning on Meeting Patient Needs after Returning Home. Health Services Research 27:155-175, 1992.
60. Mauthe, R., Haaf, D., Hayn, P., et al.: Predicting Discharge Destination of Stroke Patients Using a Mathematical Model Based on Six Items From the Functional Independence Measure. Archives of Physical Medicine and Rehabilitation 77(1):10-13, 1996.
61. McCullough, L.B., Wilson, N.L., Teasdale, T.A., et al.: Mapping Personal, Familial, and Professional Values in Long-Term Care Decisions. The Gerontologist 33(3):324-332, 1993.
62. McKeehan, K.M.: Conceptual Framework for Discharge Planning. In McKeehan, K.M., ed.: Continuing Care: A Multidisciplinary Approach to Discharge Planning. St. Louis: C.V. Mosby Company, 1981.
63. McKeehan, K.M., and Coulton, C.J.: A Systems Approach to Program Development for Continuity of Care in Hospitals. In McClelland, E., Kelly, K., and Buckwalter, K.C., eds.: Continuity of Care: Advancing the Concept of Discharge Planning. Orlando, FL: Grune and Stratton, 1985.
64. Mintzberg, H., Raisinghhani, D., and Theoret, A: The Structure of "Unstructured" Decision Processes. Administrative Sciences Quarterly 21:246-275, 1976.
65. Mizrahi, T., and Abramson, J.: Sources of Strain Between Physicians and Social Workers: Implications for Social Workers in Health Care Settings. Social Work in Health Care 10(3):33-51, 1985.
66. Morrisey, M.A., Sloan, F.A., and Valvona, J.: Medicare Prospective Payment and Posthospital Transfers to Subacute Care. Medical Care 26(7):685-698, 1988.
67. Murtaugh, C.M.: Discharge Planning in Nursing Homes. Health Services Research 28(6):751-769, 1994.
68. Naylor, M.D., and Prior, P.R.: Transitions Between Acute and Long-Term Care. In Katz, P., Kane, R.L., and Mezey, M., eds.: Advances in Long-term Care. New York: Springer Publishing, to be published.
69. Neu, C.R., Harrison, S., and Heilbrunn, J.Z.: Medicare Patients and Postacute Care: Who Goes Where? R-3780-MN. Santa Monica, CA: The RAND Corporation, 1989.
70. Neu, C.R., and Harrison, S.C.: Posthospital Care Before and After the Medicare Prospective Payment System. R-3590-HCFA Santa Monica, CA: The RAND Corporation, 1988.
71. Nice, A: Multidisciplinary Discharge Screen. Journal of Nursing Quality Assurance 3:63-68,1989.
72. Oktay, J.S., Steinwachs, D.M., Mamon, J., et al.: Evaluating Social Work Discharge Planning Services for Elderly People: Access, Complexity, and Outcome. Health and Social Work 17(4):291-298, 1992.
73. Pattison, P.: Social Cognition in Context. In Wasserman, S., and Galaskiewicz, J., eds. Advances in Social Network Analysis: Research in the Social and Behavioral Sciences. Thousand Oaks, CA: Sage Publications, 1994.
74. Peterson, K.J.: Changing Needs of Patients and Families in the Acute Care Hospital: Implications for Social Work Practice. Social Work in Health Care 13(2):1-14, 1988.
75. Phillips-Harris, C., and Fanale, J.E.: The Acute and Long-Term Care Interface. Integrating the Continuum. Clinics in Geriatric Medicine 11(3):481-501, 1995.
76. Potthoff, S.J., Kane, R.L., Bartlett, J., et al.: Developing a Managed Care Clinical Information System to Assess Outcomes of Substance Abuse Treatment. Clinical Performance and Quality Health Care 2:148-153, 1994.
77. Proctor, E., Morrow-Howell, N., and Kaplan, S.: Implementation of Discharge Plans for Chronically Ill Elders Discharged Home. Health and Social Work 21(1):30-40, 1996.
78. Proctor, E.K., and Morrow-Howell, N.: Complications in Discharge Planning with Medicare Patients. Health and Social Work 15:45-54, 1990.
79. Proctor, E.K., Morrow-Howell, N., and Lott, C.L.: Classification and Correlates of Ethical Dilemmas in Hospital Social Work. Social Work 38(2):166-177, 1993.
80. Prophet, C.M.: Patient Discharge Referral: Interdisciplinary Collaboration. Paper presented at the Sixteenth Annual Symposium of Computer Applications in Medical Care (SCAMC). Washington, DC. 1993.
81. Prospective Payment Assessment Commission: Medicare and the American Health Care System: Report to the Congress. Washington, DC. 1993.
82. Rasmusen, L.A.: A Screening Tool Promotes Early Discharge Planning. Nursing Management 16:39-43, 1984.
83. Rasmusen, L.A., and Buckwalter, K.C.: Discharge Planning in Acute Care Settings: An Administrative Perspective. In McClelland, E., Kelly, K., and Buckwalter, K.C., eds.: Continuity of Care: Advancing the Concept of Discharge Planning. Orlando, FL: Grune and Stratton, 1985.
84. Rehr, H.: Discharge planning: An Ongoing Function of Quality Care. Quality Review Bulletin 12:47-50, 1986.
85. Rich, M.W., Beckham, V., Wittenberg, C., et al.: A Multidisciplinary Intervention to Prevent the Readmission of Elderly Patients with Congestive Heart Failure. New England Journal of Medicine 333(18):1190-1195, 1995.
86. Roberts, K.H.: Some Characteristics of One Type of High Reliability Organization. Organization Science 1(2):160-176, 1990.
87. Roos, L., and Starke, F.: Organizational Roles. In Nystrom, P.C., and Starbuck, W., eds.: Handbook of Organizational Design, Adapting Organizations to Their Environment. Oxford: Oxford University Press, 1981.
88. Rubenstein, L.Z., and Josephson, K.R.: Hospital-Based Geriatric Assessment in the United States: The Sepulveda VA Geriatric Evaluation Unit. Danish Medical Bulletin, Journal of the Health Sciences 7:74-79, 1989.
89. Rudberg, M., Sager, M., and Zhang, J.: Risk Factors for Nursing Home Use After Hospitalization for Medical Illness. Journal of Gerontology: Medical Sciences 51(5):M189-M194, 1996.
90. Sainfort, F.C., Gustafson, D.H., Bosworth, K., et al.: Decision Support Systems Effectiveness, Conceptual Framework and Empirical Evaluation. Organizational Behavior and Human Decision Processes 45:232-252, 1990.
91. Schwartz, M.D.: Tracking Availability of Beds in Community Residences Through a Talking Telephone System. Hospital and Community Psychiatry 40:571-572, 1989.
92. Shaughnessy, P.W., and Kramer, A.M.: The Increased Needs of Patients in Nursing Homes and Patients Receiving Home Health Care. New England Journal of Medicine 332:21-27, 1990.
93. Shaughnessy, P.W., Schlenker, R.E., and Hittle, D.F.: Home Health Outcomes Under Capitated and Fee-For-Service Payment. Health Care Financing Review 16(1):187-222, 1994.
94. Shivley, S., Djupe, A.M., and Lester, P.: Lessons in Caring a 'Care by Caregiver' Program. Geriatric Nursing 14:304-307, 1993.
95. Shortell, S.M., Morrison, E.M., and Friedman, B.: Strategic Choices for America's Hospitals. San Francisco: Jossey-Bass, 1990.
96. Stuck, A.E., Siu, A.L., Wieland, G.D., et al.: Comprehensive Geriatric Assessment: A Meta-analysis of Controlled Trials. The Lancet 342:1032-1036, 1993.
97. Terry, M.: Essential Considerations in Setting up a Discharge Planning Program. In O'Hare, P., and Terry, M., eds.: Discharge Planning: Strategies for Assuring Continuity of Care. Rockville, MD: Aspen Publishers, 1988.
98. U.S. General Accounting Office: Post-Hospital Care: Efforts to Evaluate Medicare Prospective Payment Efforts are Insufficient. GAO/PEMD-87-SBR. Washington, DC. 1986.
99. Wacker, R., Kundrat, M., and Keith, R: What Do Discharge Planners Plan? Implications for older Medicare patients. Journal of Applied Gerontology 10(2):197-207, 1991.
100. Ware, J.E., Jr., Bayliss, M.S., Rogers, W.H., et al.: Differences in 4-year Health Outcomes for Elderly and Poor, Chronically Ill Patients Treated in HMO and Fee-For-Service Systems: Results from the Medical Outcomes Study. Journal of the American Medical Association 276(13):1039-1047, 1996.
101. Weaver, F., and Bryant, E: An Analysis of DecisionMaking in Discharge Planning. Evaluation and the Health Professions 13(1):121-142, 1990.
102. Weick, K.E., and Roberts, K.H.: (1993). Collective Mind in Organizations: Heedful Interrelating on Flight Decks. Administrative Science Quarterly 38:357-381, 1993.
103. Wertheimer, D.S., and Kleinman, L.S.: A Model for Interdisciplinary Discharge Planning in a University Hospital. The Gerontologist 30(6):837-840, 1990.
104. Wimberley, E.T., and Blazyk, S.: Monitoring Patient Outcomes Following Discharge: A Computerized Geriatric Case-Management System. Health and Social Work 14:269-276, 1989.
105. Young, Y., Brant, L., German, P., et al.: A Longitudinal Examination of Functional Recovery Among Older People with Subcapital Hip Fractures. Journal of the American Geriatrics Society 45(3):288-294, 1997.