Hospital discharge of frail, elderly patients with complex care needs: a problem or a challenge?

Abstract

Introduction: The increase in patients with chronic disease that require on-going care is creating difficulties for the public health system, which have prompted recent attempts to remodel the system with a generalized reduction in the number of hospital beds and the implementation of services designed to promote home health care. Intermediate care is an opportunity to support timely discharge from acute-care facilities and promote functional recovery, but its efficacy requires a strong, complete and comprehensive assessment to ensure appropriate admission. Materials and methods: The Care Continuity Service of Rimini is a multiprofessional team that supplies support and counselling for acute hospital wards and training for nursing and medical professionals to develop their assessment skills. Results: A questionnaire filled out by the staff of acute-care internal medicine wards in the Greater Romagna Area has revealed ambiguities in the use of terms like ‘‘social’’ and ‘‘complex care needs.’’ It also documents difficulties in the early identification of patients likely to experience problems if they are discharged from the hospital directly to their homes. Discussion: To ensure prompt identification of these patients, we must identify/develop a screening instrument or clinical-functional method that can be used in acute-care hospital wards to plan discharges. The aims of intermediate care are to reduce hospital stays and improve continuity of care, but specific know-how and expertise are needed if these goals are to be met. Specific staff training programs and a patient-centred model are essential to ensure an acceptable cost-benefit ratio.