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Table 2 Summary of important component of results
| Current Practice |
|---|
| No standardized policy/protocol for discharge process |
| No standardized tool for facilitating the discharge process |
| Piece-meal approach in individual hospital |
| Discharge program targeting high risk readmission which is based on clinical judgment and varies across hospitals |
| Disease-specific discharge program for selected diseases |
| Barriers to Discharge Planning |
| System Factor |
| Lack of guideline or polices for the standardized discharge process/care pathway |
| Piece-meal program as pilot and issue of inflexibility of program |
| Pressure on bed availability |
| Poor medication system in hospital |
| Poor communication among healthcare disciplines |
| Issue of manpower shortage and management |
| Poor regulation of care quality in old age home |
| Professional Factor |
| Unclear role of each disciplines |
| Nurses not empowered to initiate discharge planning |
| Unclear or incomplete chart documentation |
| Low awareness on patient's social needs |
| Patient Factor |
| Lack of knowledge of medication/treatment |
| Mis-concept of hospital discharge |
| Social Factor |
| Issue of services availability - waiting time, affordability, equipment loan |
| Issue of un-match needs of patients - transportation, time gap of service availability and hospital discharge |
| Poor communication/coordination between hospital and community service provision |
| Suggestion on Importance Components for Effective Discharge Planning |
| Standard screening tools to identify high risk readmission case with protocol approach and policy-driven |
| Discharge planning with multidisciplinary approach |
| Clear role of each multidisciplinary identified in the discharge planning |
| Designed nurse/physician for discharge planning as contact point |
| Clinical pharmacist for medication reconsideration |
| Trained volunteer for identification/facilitation on patient's psychosocial needs |
| Effective manpower management |
| Patient education: medication/treatment, concept of discharge process |
| Coordination between Hospital Authority/hospitals and community service provision |
| Enhance training/education on patients' psychosocial needs for physicians |
| Home carer support program to facilitate transition period from hospital discharge to home |
