Current Practice |
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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 |