| Abstract | Ensuring older adults feel prepared to discharge from rehabilitation to home is imperative for successful discharge and to reduce the risk of unplanned readmissions. Older adults account for the majority of hospital and subsequent rehabilitation admissions. With the average life expectancy increasing and the population of older adults aged 60 and over increasing it is likely that the number of older adults living in the community will continue to grow and the need for rehabilitation will increase. It is important to ensure that when older adults undergoing rehabilitation are ready for discharge back home, the transition from hospital to home is successful and preventable readmissions are avoided.
The discharge planning process for older adults in rehabilitation is often complex and multifactorial. Discrepancies in perceptions of readiness for discharge have been shown between the rehabilitation team and patients. Involving the patient in the discharge planning process from an early stage may be beneficial in terms of successful discharge and minimising the risk of unplanned readmission. There is much to consider from a Physiotherapists’ perspective when planning complex discharge for older adults including; physical function, coping, expected support, confidence, mood, environment and social supports. This may present a challenge for physiotherapists who have little or no experience with complex planning and clinical reasoning. This program of research was designed to explore patient perceptions of readiness for discharge and other factors involved in discharge including physical function, balance, mobility, balance confidence and depression risk. Additionally, this program of research aimed to increase understanding of patient and physiotherapists’ experiences with rehabilitation discharge and discharge planning.
Five studies were undertaken in this thesis, two quantitative and three qualitative. Study 1 was a quantitative study and explored the relationships between patients’ perceptions of their readiness for discharge and measures of function, balance, depression risk and balance confidence. Patients’ perceptions of readiness for discharge were assessed using a validated tool, the Readiness for Hospital Discharge Scale. The Readiness for Hospital Discharge Scale is comprised of four sub-scales; physical status, knowledge, coping, expected support. Outcomes measured included balance, gait speed, mobility, function, risk of depression and balance confidence. The cohort consisted of 101 older adults who had undertaken inpatient rehabilitation and consented to undertake outcome questionnaires and routine physical testing prior to discharge to home in community. The majority of older adults reported feeling ready for discharge. Higher levels of readiness for discharge correlated with higher scores on physical testing and lower levels of expected support post-discharge. Patients also scored relatively low on balance confidence and were below the threshold for depression risk prior to discharge to home.
Study 2 was a quantitative design and explored the same cohort to investigate if perceptions of readiness changed after one-month post-discharge. Study 2 findings indicated that patients tended to overestimate their readiness for hospital discharge at discharge. Self-reports of physical status, expected support and balance confidence decreased after being home in the community for one-month, while the risk of depression increased marginally.
Study 3 examined both the formal and informal factors considered by experienced rehabilitation physiotherapists when discharge planning for older adults. A focus group with semi-structured interview questions was used with experienced physiotherapists who had worked in rehabilitation for more than five years. Experienced physiotherapists appeared to take a ‘down the track’ perspective when planning discharge. While the current status of the patient was assessed and taken into consideration, experienced physiotherapists also anticipated disease progression, functional or cognitive decline and the likelihood of change in the future.
Study 4 explored the factors considered by novice physiotherapists when discharging older adults from rehabilitation. A qualitative design focus group was conducted with six novice physiotherapists who had less than three months experience in rehabilitation. The same semi-structured interview questions were used for the novice group as for the experienced physiotherapists. Novice physiotherapists are comprehensive when checking function and mobility and have a good insight into the complex nature of discharge planning from rehabilitation. However, they reported forgetting to check on certain aspects related to discharge until the last minute.
Study 5 was a qualitative design and explored patient perceptions of their readiness for discharge at two timepoints. Semi-structured interviews were conducted one on one and face to face with patients within 72 hours prior to discharge. Prior to discharge, only half the cohort reported feeling ready. However, once home, all patients reported retrospectively they actually were ready to return home when discharged. All reported improved function and mobility post-discharge and overall, patients reported a positive experience with their time in the rehabilitation unit, and the transition from hospital to home.
The findings of this program of research indicate a concerning trend where older adults tend to overestimate their readiness for discharge, physical capacity and the amount of support expected once back at home in the community. There also appeared to be an increase in depression risk one-month post-discharge. With a growing ageing population, successful discharge from hospital and the need to prevent unplanned readmission is paramount to reduce unnecessary burden on the health care system. This body of research may help to inform future directions on areas of required research, information dissemination to health providers and how to best help keep our older Australians living in their own homes for longer. |
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