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