MCGILL UNIVERSITY INTERDISCIPLINARY DISCHARGE PLANNING ROUNDS: IMPACT ON TIMING OF SOCIAL WORK INTERVENTION, LENGTH OF' STAY AND READMISSION

MCGILL UNIVERSITY INTERDISCIPLINARY DISCHARGE PLANNING ROUNDS: IMPACT ON TIMING OF SOCIAL WORK INTERVENTION, LENGTH OF' STAY AND READMISSION A Thesls Submltted to the School of Social Work F clculty of Graduate Studies and Research In PartIal Fui f 11lment of the Requirements for The Master's Degree in Social Work (c) by Iryna M. Dulka Montreal, September 1993

MCGILL UNIVERSITY INTERDISCIPLINARY DISCHARGE PLANNING ROUNDS: IMIPACT ON OUTCOMES A THESIS SUSMITTED TO THE SCHOOL OF SOCIAL WORK FACULTY OF GRADUATE STUDIES AND RESEARCH IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE MASTER'S DEGREe:: IN SOCIAL WORK (c) SY IRYNA M. DULKA MONTREAL, OCTOBER 1993

ABBTRACT This study examlned th~ effect of Interdlsclpllnary discharge planning rounds on timing of social work lnterventlon, length of stay (LOS), and readmlsslons for pat lents aged 55 and over. Data sources were the medlcal charts of 449 pat lents dl schar'ged durlng two corresponding 28 day perlods (one before and one after the lmplementatlon of rounds) supplemented by Dlscharge Planning Commlttee minutes (OPCM) and lntervlews wlth four key lnformants. No slgn 1 f 1.cant dlfferences ln the tlming of social work Intervention, LOS, or readmlsslons were found between the two sampi es. Qualltatlve resœarch revealed that essentlal components were elther mlsslng (physlclan partlclpatlon), or not unj. forml y lnc 1 uded (famlly participation) ln rc)unds, and that staff felt that rounds lmproved communication amcng th~ dlsclpllnes and contr lbuted to Improved e'fflc Jency in plc1lnnlng hosp 1 tal and posth03p 1 tal se,"vlces. T"e!:.e f 1 nd 1 ngs hlghllght the need ta furthe!r 'study al1 asp~cts of the complex dlscharge planning to Identlfy factors that would reduce LOS and readmlsslons.

Cette étude a porté sur l'impact de séances multldlsclpllnaires de planification des congés sur 1 e moment choisi pour les lnterventions sociales, la durée du séjour et la fréquence de réhospltallsatlon chez des patients âgés de soixante-cinq ans et plus. Les dollnées ont été t ll'"ées de trois sources dl fférentes, SOlt: les dossiers médicaux de 449 patients qui ont reçu leur cong~ du cours de l'une de deux périodes correspondantes de 28 Jours (la première avant la mise oeuvr~ des séances de planiflcatlon et la seconde, après), les procés-verbaux des séances du comité de planification des congés et, enfin, les lnformations obtenues lors d'entrevues avec quatre Informateurs clés. On n'a démontré aucune différence significative entre les deux échantillons en c~ qui concernp le moment de l'lnterventlon sociale, la durée du séjour et la fréquence de réhospltallsation. Une évaluation qualitative a révélé, d'une part, que des élément!! essentiels manqua lent (participation des médecins> ou n'avaient pas été Inclus de façon systématique dans les séances multldlsclpllnaires (pilrtlclpation de 1 a famille) et, d'autre part, que le personnel trouvait que les séances de plan! hciltlon favorisalent les échanges interdisciplinaires et une planification plus efficace des services hospitaliers et posthospitallers. En conclusion, ces résultats soulignent que l'on doit mener des études plus approfondies sur tous hi

les aspects du processus complexe qu'est la planification du congé, si l'on souhalte ldentlfler les facteurs qul permettraient de rédulre la durée du séjour et la fréquence de réhospltallsatlon. iv

ACKNOWLEDGEMENTS My Slncere thanks are extended to my thesls advlsor, Sydney Duder, for stlmulatlng my lnterest ln research, for her patlence, unwaverlng enthuslasm and her expertise. l want to thank Lllly Katofsky, who flrst encouraged me to conduct research on thls partlcular subject, who gave of her tlme for consultations, and who made lt possible for me to acqulre the data used ln thls study. Thanks to Dr. MoraleJo, at St. Mary's HospItal, for permission to conduct thls study, and to the very helpful staff ln the MedIcal Records Department. l am also Indebted to the four people who made tlme ln their very busy schedules to be Intervlewed, and whose contributions are so valuable to thls study. To my payents--my earllest teachers, thank you for glvlng me the love of learnlng and YOUr support. l also want to thank my brother for hls reassurances, and my frlend, Marsha, for her encouragement and for agreelng to do my share of dlshes throughout my thesls-wrltlng perlod. v

TABLE OF CONTENTS ACKNOWLEDGEMENTS LIST OF TABLES LIST OF figures v VIIl lx 1. INTRODUCTION 1.1 Focus of the Study.......... 1 1.2 Case MlX Groups. 3 1.3 Discharge Planning....... 5 1.4 Health Care, Hospltallzatlon, and Older Patients 6 1.5 Length of Stay, Delayed Dlscharges, and Readmissions 8 1.5.1 Pat lent S~tlsfactlon and 1. S. 2 1.5.3 1.5.4 Partlclpatlon Pat lent Follow-Up Other D1SC~aYge Plannlng Obstacles.. Dlscharge Planning Audlt 11 12 13 15 1.6 Information Retrleval for Research Purposes 15 1.7 Interdisclpllndry Olscharge Plannlng at the Hospltal 16 1.7.1 Tradltlonal Procedure... 1/ 1.7.2 Revised Discharge Plannlng Protocol........ 18 1.8 Study DeSign 19 VI

2. METHODOLOGY 2.1 Sample.. 2.2 Data Collectlon.. 2.3 Data and Chart Problems 2.4 AnalYS1S...... 2.4.1 Data from Medical Charts 2.4.2 Data from Dlscharge Plannlng Commlttee MInutes. 2.4.3 Data from Interviews 3. FINDINGS 3. 1 Descrlptlon of the Sdmple 3.2 Ef fec ts of the Dlscharge Planning Rounds.. 3.3 COlltrolllng for Demographlc and Illness-Related Varlables 3.3. 1 Path Analyses 3.4 DPC MInutes and Interviews 3.4.1 Attend:once at Rounds 3.4.2 Reasor.~ for Delayed u1scharges 3.4.3 Physlc Hm Partlclpatlon 3.4.4 Patient Part1c1patlon 3.4.5 Dlscharge Planning Form 3.4.6 Increased Workloads 3.4.7 Beneflts Derived from Rounds 3.4.8 Recordlng Problems 21 22 23 24 24 29 30 32 36 41 45 49 49 49 54 56 57 58 61 62 4. DISCUSSION 4.1 Key Flnd1ngs 4.2 Llmltat10ns of the Study 4.3 Impl1cat 10ns 4.3.1 Impllcatlons for Research 4.3.2 Impl1cat1ons for Pract1ce 65 67 68 68 71 APPENDIX 1. Data Collectlon Instrument APPENDIX 2. Recod1ng Var1ables REFERENCE LIST 7S 78 81 Vil

LIST O~ TABLES 1. Demographie Variables, by Year 33 2. Status Prlor to Hospltallzatlon, by Year 35 3. Admission Informatlon, by Year 37 4. Hospltallzatlon and Dlscharge Information, by Year. 38 5. Outcome Variables, by Year 40 6. Predlctors of Year to Year Change: Stepwlse Regressions 42 7. Predlctors of Year to Year Change: Block Regression 44 V1l1

LIST OF" F"IGURES 1. Relatlonshlp Between Variables: Causal Model..... 27 2. Predictors of Social Work Interventlon: Path Diagram........... 46 3. Predlctors of Length of Stay: Path Dlagram............. 48 4. Predictors of Readmissions: Path Diagram............. 50 ix

1.1 (oeu. of the Study 1. INTRODUCTION CurY"ent economlc condltlons compelllng hospltals, the largest lnstltutlons wlthln the heal th care system, ta provlde hlgh-quallty care whlle lntroduclng effectlve cost-contalnment strategles (Edwards, Rell ey, Morls & Doody, 11313 1; FaY"ren, 1991 ; Navak, 1988; Taylor, 19131). Proposed changes ln health care flnanclng, comblned wlth the recognlzed detrlmental effects of lnstltutlonallzlng aider persons, have been plvotal ln motlvatlng health care professlonals to become more effective and efficient ln enabllng patients to return to, and health. and malntaln, thelr optlmum standard of llfe stemmlng from the drive for lncreased efflclency and effectlveness, some hosp 1 tal sare lnterdisclplinary dlscharge planning rounds. lmplementlng On February 4, 1991, lnterdlsclpllnary dlscharge plannlng rounds were lnstltuted on every medlcal and surglcal unit of the 414 bed, acute care, university-afflilated hospltal (from now on referred ta as the Hospltal) WhlCh served as the settlng for thls study.

2 The rounds were seen as a way to streamllne the process by WhlCh patients' progress, and thelr needs upon dlscharge, could be Identlfled, monltored, dlscussed and planned for (L. Katofsky, Dlrector of SocIal SerVIces, personal communlcatlon, January 18, 1993). Moreover, at the Hosp 1 tal' s Discharge PlannIng Commlttee's (OPC) Oc t :>ber 19, 1991 meeting, was reported that the Canadlan HOspItal Management Research Instltute (CHMRl)l, had establlshed the Hospltal's average length of stay (LOS) across seven servlces for the prevlous year, as 5200 days above the national norm. The development of dlscharge planning rounds was therefore regarded as t1mely, as the longer stays had caused man y d1ff1cult1es ln terms of bed d1stributlon and hosp1tal resource allocat lon. The purpose of th1s study was to establlsh whether Interdisclpllnary d1scharge planning rounds contr1bute to changes ln the t1m1ng of soc lai work 1ntervent 10n, to shorter LOS, and to fewer readm1ss10ns for pat lents aged 65 and over. The rat10nale for th1s study grew from earl1er stud1es Wh1Ch found that 1nterdlsc1pllnary dlscharge plannlng rounds reduce hospltal1zation costs, CHMRI 1S a Canad1an, company that special l,es ln 1nformat1on serv1ces. federally chartered independent pat1ent-spec1f1c health related

3 Increase qualltyof care, and provlde optimum patient care post-hospltallza~lon, thus reduclng the llkellhood of readmlsslons (Berkman, Camplon, Swagerty & Goldman, 1983; Edwards et al., 1991; Hauser, Robinson, Powers & Laubacher, 1991; Thllverls, 1990). Berkman et al. (1983) studled the effects of the development of a Gerlatrlc Consultation Team (GCT> WhlCh met twlce weekly to dlscuss patlents' needs upon dlscharge, and to provlde follow-up assessments of patients' progress postdlscharge. Thelr results Indicated a slgnlflcantly longer LOS, although they were able to llnk better quallty of service dellvery, Increased utlllzatlon of soclal health services, and a reductlon of recurrent early readmlsslons, to the work of the GCT. Wertheimer and Klelnman's (1990) study of interdlsclpllnary dlscharge planning, however, found no dlfferences ln LOS between patients whose dlscharges were planned ln an InterdlSClpllnary settlng, and those whose discharges were planned ln the tradltlonal way. 1.2 C "lx Group. Diagnostic Related Groups <DRGs) were developed ln the Unlted States to categorlze patients Into relevant and meanlngful groups on WhlCh standard fundlng rates could be est ab Il shed. These groups are based on

4 dlscharge dlagnosls, utillzation of hospltal-based services and length of huspltal stay--in other words, standard hospltal "products" (Botz ~ Devereux, 1991 ; Ho f f man, 1985 ) In 1983, CHMRI Introduced Case MIX Groups (CMGs) WhlCh were modeled on DRGs, as a means of organlzlng dlscharge Information wlth regard to patient lilness and hospltallzatlon to make It possible for hospltals to monitor and manage resource utillzation more effectlvely (De Groot, McDonald, Peabody & Sheppard, 1992). CMGs are now belng utillzed in certain segments of the Canadlan health c~re system, as a fundlng mechanlsm ln response to demands for Increased accountablilty (Botz ~ Devereux, 1991>. In Canada, thls means that ultlmately ail hospltal budgets will no longer be determined by the actual workload ~elated to a patlent's hospltallzation, but on the expected workload correspondlng to the patlent's asslgned CMG category (Botz & Devereux, 1991). CMGs were Introduced at the Hospital ln November 1991 for the pur pose to CHMRI. At the Hospltal's management of reporting cllnlcal patient data tlme, It was expected that the of CMGs would be evaluated for budgetary purposes and to see how the Hospltal's performance compared wlth that of other similar patient

5 groups ln other hospltals Dl rec tor of Social SerVlces, personal commun 1 C at Hm, January 18, 1993) 1.3 Di.charge plannidq The dlscharge plannlng process must Include the ldentlficatlon of patlents who may be at r15k upon dlscharge, and the assessment of thelr SOC lai and health care needs, ln order to plan and co-ordlnate the services and supports that they wlil need at dlscharge (Berkman, Mlilar, Holmes ~ Bonander, 1990). Dl~charge plannlng ls cruclal to quallty patlent care, and actlve partlclpatlon of ail health care provlders lnvolved ln a patlent'5 care ls essentlal to the success of the dlscharge plannlng process (Blumenfield, 1986; Hauser et: al., 1991; Jesse ~ Doyle, 1984; Wacker, Kundrat Sc Keith, 1(391). In a social work context, dlscharge planning 15 defined as the process in WhlCh SCCldl workers counsel patients and thelr famliles ln relatlon to SOC lai and envlronmental dlfflcultles assoclated wlth lliness, hospltallzatlon, and posthospltal Cdre (Berkman, Mlilar, Holmes ~ Bonander, 1990). AlI thls ls sald to contrlbute to the reductlon in LOS and readmlsslons, as patient, patlent's famlly, and communlty resources gather an understandlng of the patlent's health deflclts and health

care needs at dlscharge <Berkman et al., 1990). Marchette and Holloman < 1986), however, ln thel r study of 500 patients at a medlcal center (average age 72 years) found that pat lents who recelved soc lai work InterventIon for dlscharge planning stayed ln hospltal 7.6 days longer than pat lents who had no contact wlth soc lai workers. They explalned that the longer LOS for pat lents who had contact wlth soc lai workers was because they were probably fraller and ln poorer health; these were the pat lents who needed more postdlscharge asslstance, or who were not returnlng to thelr homes, and therefore needed assistance wlth the placement process. 1.4 H.alth Car Ho.pttaltzatton. and 01d.r Patt.nt. Lengthy or unnecessarlly prolonged hospltallzatlons have been described as a serlous problem in the medical care of the elderly (Alexander, 1990; Berkman et a1., 1983; Johnson & Fethke, 1985). Regardless of a patlent's age, however, hospltallzation is often dlfflcult to adjust to because of the unusual routine, uncomfortable procedures, and loss of prlvacy, self-esteem, and lndlvlduallty; these losses can 1 ead to a radical alteratlon of role and self-lmage (Berkman et al., 1983; Blumenfleld, 1983; John~on & F"ethke, 1985; Malllck, 1983).

Among the 7 older population, as ln ~ounger population groups, gender, dge and SOClo-economlC status govern how one percelves the need for, and th~ d@llvery of, heülth and social servlces <Slmmons, 198&; UJlffiotO, 1988). Ethnlclty or culture also provldes an Important basls for assesslng pat lent needs, bath durlng hospltallzatlon and dlscharge planning <Henkle Kennerly, 1990; UJlmoto p 1988). The stress of hospltallzatlon, If comblned wlth grievlng over a recent loss, or fear of permanent, partial oy complete 1055 of independence, may render a person's usual coplng mechanlsms Ineffectlve (Johnson & Pethke, 19B5). There IS a also a growlng body of llteratu~e that exposes the latrogenlc effects of medlcall~atlon IlllCh, 1975; and Klnes, hospltallzatlon (Alexander, 1990; 1989). AlI these elements underllne the Importance of reducing and ellmlnatlng, whenever posslble, unnecessarlly prolonged hospltal stays for older patients. Currently, a comblnatlon of new tec~nologies and pharmacologies make the ellmlnatlon of hospltallzatlon possible ln certain cases; for example, more of certain surglcal procedures are performed on an out-pat lent basls. As a result, a hlgher proportion of the patients

8 over-65, who are belng hospltallzed today are serlously 111 and have potentlally greater psychosocial needs related to thelr Illness (Peterson, 1987), 1.5 Length of St.V, Delayed Discharges, and Readmissions Delayed dlscharges have been the focus of several studles of hospltallzed elderly. A delayed dlschar~e is deflned as the perlod of tlme past the date the patient ls consldered medlcally ready for dlscharge, and the date that the patlent ls actually dlscharged. Delayed dlscharges are a burden on hospltal resources, and can be especially hard for older patients and ~helr famliles (talcone, Bolda & Crawford Leak, 1991). Studies have been conducted ln an ef fort to determlne which hospl tal admlssion and discharge procedures are most effective ln lmprovlng pat lent satlsfactlon and well-belng, and ln controlllng health care costs related to hospltal readmlsslons (Farren, 1991; Hauser et al., 1991; Jackson, 1990; WertheImer Sc Klelnman, 1990). Hauser et al. (1991> found that the development of an Interdlsclpllnary team, where members worked together to provlde comprehensive evaluatlon and treatment plans to pat lents who no longer requlred acute medlcal care, resulted in a 1.4 day decrease ln average LOS and also lmproved dlscharge status. Berkman et al.

9 (1990), Marchette and Holloman (1986), and Naylor (1990b) found that pat lent LOS can be reduced, rehospltallzatlons prevented, and optlmal patient outcomes attalned, through the Implementatlon of effective and tlmely hospital dlscharge planning. Marchette and Holloman (1986) found that pat lents admltted from thelr own home, but discharged to a nurslng home, had hospltal stays that were 10 to 12 days longer than other pat lents. Schrager et al. (1978) Ident 1 fled several factors contrlbutlng to delayed patient discharges and longer LOS: late referrals from medlclnej incomplete referral or transfer forms from mediclne, nurslng or thelr afflilated professlons; unavallablilty of posthospital dlscharge beds, and unantlclpated changes ln, or deterloratlon of, the patlent's medlcal status. Kennedy, Neldllnger & Scrogglns (1987) found that comprehenslve dlscharge planning for pat lents aged over 75 resulted ln LOS that were two days shorter for patients ln the treatment group when compared to the control group. Farren <1991> also found that discharge planning lmplemented wlthln 24 hours of hospltallzatlon, resulted ln a two day decrease ln LOS for pat lents ln the experlmental group who had been systematlcally admltted Into the study. Falcone et al. <1991> however, reported

10 that pat lent age, race and need for heavy care were factors ln delayed dlscharges; unavallabliltyof post hospltal beds was not a signlflcant predlctor of delayed discharge. In thelr experlmental study, Kennedy et al. (1987) found that pat lents who had recelved comprehenslve dlscharge planning were readmltted an average of 11.2 days later than pat lents ln the control group. Wlmberly and Blazyk (1989) concluded that poorer and older patlents had more frequent and eariler readmlsslons. They found that pat lents Wlth lncomes hoverlng close to the poverty llne were less llkely to benefit from homedellvered meais and collectlve or communlty meals and outlngs, and were more prone to hardship as a resuit of thelr Inablilty to pay for priv~te servlces while on waiting llsts for government SUbsldized services. Jackson (1990) found that patlents at greatest risk for readmlsslon were those who received the most communlty based homecare servlces, llved aione, had the greatest number of medlcal and nurslng diagnoses, and were the frallest, though not necessarlly the oldest, patlents. The decllne of physlcal actlvity that often results from lengthy hospltai stays has aiso been Ilnked to early readmisslons (Berkman & Abrams, 1986).

1 1 Vlctor and Vetter (1985) found that readmlsslons were not related to patients's social 01'" demogl'"aprllc charac ter lst lcs, but were a result of relapses and bre~kdowns ln the pat lents' orlglnal medical cond I t lons. They also found that pat lents' own pel'"ceptlons of readlness for dlscharge Influenced whether 01'" not they were readmitted. Werthelmer and Klelnman (1990) agreed wlth these flndlngs, and stated that pool'" dlscharge plannlng ls not necessarlly to blame for readmlsslons. 1.S.1 Pati.nt Satisfaction and Participation Hosp 1 tal admlnlstrators al'"e paylng more attent10n to patlents' satlsfactlon wlth care (Berkman, Bedell, Parker, McCarthy & Rosenbaum, 1988; Kennedy et al., 1987; Moher, Welnberg, Hanlon & Runnalls, 1992). Among the outcome measures, patient satlsfactlon ls lmportant when to determlne whether the ObJectIves of new patlent-centered procedures are belng met (Dake, 1984; Hedrlck et al., 1991). Pat lent oplnlons about thelr hospltal care have been found to lnfluence thelr Vlew of the health care system, and to determlne thelr partlclpatlon ln plans for p05t-hospital care. Pat lent satlsfactlon 15 seen as havlng a dlrect posltlve.mpact on enhanced patient compllance, WhlCh ln turn affects h osp 1 t ail z a t Ion

outcomes (Courts, 1988) 12 It ls prlmarlly among older patients that elevatlon ln health status, and lncreased pat lent s~tlsfactlon, are Ilnked wlth effective dlscharge planning procedures (Haddock, 1991). Increased p~tlent lnvolvement dlscharge planning, especlally soon after admission, has been found to be effective ln decreaslng LOS and lncreaslng patient and patient famlly satisfaction. Where pat lents and famliles agree ta partlclpate, thelr lnvolvement enhances thelr knowledge of hospltal procedures whlch ln turn promotes a greater sense of control and contrlbutes to lmproved patient well-belng, a greater sense of selfresponslblilty, and lncreased confidence for recovery (Abramson, 1990; Farren, 1991; Wac ker et al. 1991). 1.~.2 Patient ~ollow-up Ar cord lng t 0 Muenchow and Carlson (1985), evldence that the planned contlnulty of care was provlded, and that patients returned to the most lndependent level of care possible, are the two outcomes that most eff~ctlvely measure success of the dlscharge planning process. Jackson (1990), and Jones, Densen and Brown ( 1989), confirm the need for the contlnuous assessment of the dlscharged patlent's potentlally changlng needs.

13 Jones et al. (1989) found that many discharged pat lents were unaware of the community serv1ces ava1lable to them, and that no one had talked wlth them about communlty services wh1le they were hospltallzed. Followup ls crucial; ev en patlents whose health care needs have been met may have unresolved llmltatlons that are physlcal, soclal, or envlronmental ln nature, WhlCh place them at r1sk for poor dlscharge outcomes, such as the decllne ln health and well-belng, and consequent readmlss10n (BI~menfleld Klelnman, 1990). & Rosenberg, 1988; Werthelmer & 1.S.3 Other Di.charge Planning Ob.tacl The goal of d1scharge planning for older pat lents should be the preventlon of unnecessary, premature, and avoldable hospltal readmlsslons CNaylor, 1990a). What would be consldered efflclent and effectlve hospltal dlscharges by pat lents and hospltal staff may, however, requlre more than the plannlng for a safe and stable trans1t1on from hospltal to posthospltal destlnatlon (Werthelmer & Klelnman, 1990), Any organlzatlon made up of lndlvlduals wlth varlous capagllltles and personal phllosophles must face the lssue of multiple loyaltles; loyaltles to the organlzatlon, to the posltlon held, and to the professlon

14 (Etzlonl, 1964; Ker foot St Kelly, 1985; McKeehan, MacDonald Walsh ~ Paplle D'Day, 1981). The timing and clrcumstances ln WhlCh dlscharge planning tasks must be c ar~ led out, comblned wlth the lnte~dlsclpllnary Impl1catlons, cont~lbute to the complex1ty of the hospltal d1scha~ge planning process (P~octo~ St Mo~~ow- Howell, 1990) However, Mohe~ et al. (1992), a~gue that discha~ge planning, wlth lts potent1al for expedlent discha~ges, can not only have a positive Impact on patients but can also gene~ate posltlve feelings among the profess10nals lnvolved. Impo~tant to consider ls that membe~s of the med lcal sta f f, p~lma~lly the physlcians, a~e held accountable fo~ dete~mlnlng patient ~eadlness for discharge (Procto~ L Horrow-Howell, 1990). We~theimer and Klelnman (1990), ln p~esentlng a model for lnte~dlsclpllna~y dlscha~ge planning found that, Wl thout physlc~an participation on t~aditlonal ~ounds, the discharge plannlng teams could not conduct p~oductlve and effectlve discha~ge planning. F'u~thermo~e, a greate~ number of patients ldent 1 hed as being in need of inte~disc Ipl inary discharge plans translates lnto inc~eased wo~kloads fo~ the p~ofesslonals involved. Often, the implementatlon of

15 procedures WhlCh result ln lncreased workloads LS not coupled wlth increases ln staff. If not addressed, increased workloads could create resentment ~mong the professlonals affected, and could also Interfere wlth the delivery of servlces. Another factor to conslder in interdisclpllnary dlscharge planning ls that ln hospltals as in many other settlngs, professlonals are often heard complainlng about the number of meetings they must attend, and about the reams of paperwork for WhlCh they are responsible. Professlonals often state that tlme spent on paperwork and meetings ls tlme taken away from clients (Ml1ner, 1980). I.S.4 Di.charg. Planning Audit Jesse and Doyle (1984) developed and studled an audit in an acute care hospltal. The audit served to ident 1 fy and solve problems rel ated to discharge shortcomings, and contrlbuted to Interdlsclpllnary teamwork essential for discharge planning. Thliveris (1990), ln a study of a Canadlan general hospltal, also found that a hospltal-wlde dlscharge planning program, that Included an audit, improved hospltal and communlty resource utllizatlon. 1.6 In'gr.at'on R.tr'wv.l 'or R... rcb Purpo... Problems wlth incomplete assessment forms have been

16 ldentlfled ln several studles of dlscharge planning (Cake, 1984; Hagan Hennessy" Shen, 1986; Jesse & Doyle, 1984). Some studles of dlfferent models of dlscharge plannlng have hlghllghted the need for accuracy ln the screenlng process, and have polnted to screenlng procedures WhlCh fall to accurately examlne or record patient posthospltal needs (Iglehart, 1990). The varying needs and objectives of dlfferent health care professlonals, ln terms of what each Vlews and records as relevant and essentlal InformatIon, have been clted as generally problematlc for researchers trylng to conduct patient-centered studles (Hagan Hennessy & Shen, 1986; Iglehart, 1990). ror example, patients may not routinely be asked about their flnanclal situation, even though studles show that the limltatlons experienced by patients who are poor contribute to the llkelihood of unsuccessful discharges (Wimberly " Blazyk, 1989). 1.7 Intwrdl.,lpllnary DlwebarAw plannina at thw HO.Dit.1 The idea of weekly lnterdisclplinary dlscharge planning rounds was concelved at the Hospital ln rebruary 1989, malnly ln response to severe overcrowding of the Hospltal's emergency room. These rounds were seen as a way of maklng the dlscharge process more effective through the lmproved identification of patients who would requlre transfers to rehabilitatlon institutions,

17 referrals to Local Communlty Health and Social Service Center~ (CLSCs), or who would need other dlscharge planning ~nterventlons CL. Katofsky, Olrector of Social Services. personal communication, January 18, 1993). 1.7.1 Tradition.1 Procedure The Hospital's tradltlonal dlscharge planning procedure lncluded a system whereby a team composed of the liaison nurse, the geriatrlc nurse consultant, and the director of the SOCial Work Department, would meet wlth the head nurse of each unit to revlew the patients on that unit. Although this system was valuable ln identifying and planning for patients ready for discharge, lt had one main disadvantage--each of the eight unlts were visited once per month. In terms of SOCial work lnvolvement, patients could be referred to the SOCial Work Department by the physiclan or nurse in charge, or at tlmes the patient or patient's family would request SOCial work assistance. The danger of not havlng a weekly revlew of patient progress was that a patlent's condition could deterlorate later ln the hospltallzatlon, or referrals would not be tlmely, making a successful discharge more dlfflcult to plan (OPCM, March 1, 1991).

18 1.7.2 R.vi d Di.charg. Planning Protocol Weekly lnterdlsclpllnary dlscharge planning rounds were lnstltuted on every medlcal and surglcal unit of the Hospital on February 4, 1991. Discharge planning became the responslbllity of the Interdisclpllnary dlscharge planning teams of each unit; these were comprised ot representatlves trom nurslng, nurslng liaison services, rehabliitation and social work services, and were led by the head nurses of each of the elght units. While representatlves trom medlclne dld not attend the rounds, communication was expected to flow between the physicians and the head nurses (St. Mary's Hospital Center, 1991b). ln conjunction with the development of the dlscharge planning rounds, a Discharge Planning Committee (OPC) was tormed. Members included representatives from Nursing, Social Work, Rehabilitation Services, Liaison, Gerlatrics, Hospital Administration, and Famlly Medicine. who lnitlally met at least SIX tlmes a year, and later, on a monthly basis (DPCM, October 4, 1991), to ensure conslstency ln the ë~pllcation of the Oischarge Planning Model, and to coordinate and monitor the actlvlties of each of the teams (St. Mary's Hospital Center, 1991b). An Important dlfference between the traditional system and the guldelines establlshed for the new

19 InterdlSClplinary dlscharge plannlng rounds, was that with rounds, prlntouts of patient names were prepared and dlstrlbuted each week prlor to rounds, ln order that each discipline could come prepared wlth an update of the patients that they were followlng and that had been dlscussed the previous week (St. Mary's Hospltal Center, 1991b). ThlS new dlscharge tool--the llst of patient names--was used to gulde dlscusslon for dlscharge planning (DPCM, May 3, 1991). Through rounds, attendlng members of the Social Work Department could ldentify pat lents who would potentially beneflt from SOCial work lnterventlon. Social workers became engaged ln a more actlve role in the ldentlflcation of, and planning for, patients' needs durlng hospltalization and at dlscharge (L. Katofsky, Director of Social Services, personal communlcatlon, January 18, 1993). 1.8 Study D ign ThlS study was deslgned as a year-to-year comparison of patient outcomes. The purpose was to examlne the ~ffects of lnterdlsciplinary dlscharge pl~nning rounds on the tlming of SOCial work lnterventlons, LOS, and readmisslon rates, as compared to the hospital's traditl0nal general dlscharge plannlng

20 procedure. A comparlson of lnformatlon ln the medlcal charts of pat lents dlscharged durlng two correspondlng perlods, one before and one after the lntroductlon of rounds, was made. Because no m~tchlng or randomizatlon was posslble, the analysls was deslgned to control for year-to-year dlfferences ln demographlc variables <e.g., gender, religion, age, b1rthplace, marital and employment status, and Ilv1ng sltuat10n), and ln slckness-related variables <e.g., functlonal status, type and nature of admlssion, dlagnosls, and expected LOS) that had been found ln other studles to affect outcomes.

2:L 2. t1ethodologv 2.1 Sampi. The data were collected from the medlcal charts of two groups of pat lents (N=449) aged 65 and over, who were dlscharged durlng two correspond1ng 28 days perlods ln 1990 and 1992, that ls, one year before and one year after the lmplementatlon of Interdlsclpllnary dlscharge planning rounds. A retrospectlve revlew of the data was conducted and a comparlson deslgn was used for analysls. In 1990, 212 pat lents aged 55 and over were discharged between January 28 and February 24; 237 patients were discharged durlng the correspondlng perlod in 1992 (February 9 to March 7). Of the total 449 pat ients, 395 remalned in the study sample after el iminat lng the char"cs of those who durlng hospltalizatlon, or whose hospltallzatlons had been classified as long terme Long-term patlents are those who have been ldentlfled by the1r treatlng physlclan as unable to return to the settlng from WhlCh they were adm 1 t t ed (i. e., own home, home of a relative, or foster home), and who no longer requlre active medlcal treatment or attention (St. Mary's Hospltal Center, t991a).

22 2.2 Data Collection The medlcal charts were examlned to determlne dlfferences ln tlmlng of soclal work lnterventlon, LOS and readmlsslon rates between the two groups. As 1 t was difflcult to establlsh from the medlcal charts whether any lndivldual pat lent had been discussed durlng dlscharge plannlng rounds, the overall statlstlcs for each sample were compared to determlne lf there were signiflcant dlfferences between the two samples. Medical, nurslng and admisslon records ln the charts were revlewed for socio-demographlc data such as age at admission, gender, marltal status, functional status, Ilvlng situation, recent major life events, preand post-hospitallzatl0n homecare services, health status, LOS, and readmisslons. Social work notes that were ln the charts were revlewed for evldence of tlmlng of soc lai work Interventions and for addltional psychosoclal lnformation (see Appendlx 1). Detalls of the hospltallzatlon itself were limited to type of admission (emergency, semi- or non-emergency), the maln diagnosis, pat lent compllancy hospltallzatlon, admlsslon and discharge dates, during dlscharge destln.tlon and the reason for, and tlming readmisslon or return to emergency room. of, any

23 Upon admission to hospltal, a patlent's main diagnosis may not always be evldent, and may only be determlned after approprlate medlcal tests are conducted. The computerlzed prlntouts of the physlclans' records were therefore studled to determlne the ~aln dlagnosls and CMG for each patlent (Appendl~ 2), and to establlsh whether the hospltallzatlon was medlcal or surglcal ln nature. 2.3 Da'a and 'Char' proble The information ln the medical charts was recorded by different professionals (e.g., nurses, physic lans, occupatlonal theraplsts, soc lai workers, and physlcal therapists) on varlous hospltal forms, maklng lt sometimes hard to locate the necessary pertinent information. Handwrlting was at tlmes difflcult to decipher, and certain hospltal forms, such as the Patient Proh 1 e F"orm, were often Incomplete or contalned informatlon that was not helpful ln determlnlng the patlent's si tuat ion before hospltallzation and after discharge. Important Information was elther mlsslng or not easlly found ln the charts; for example, patients were not routinely asked about their flnanclal situation. For the question related to the living Situation of the patlent before hospltallzatlon, the response often

24 recorded was that the patlent 11ved ln an apartment or house; the lnformatlon lmportant for effectlve dlscharge plannlng ls whether the patient lives alone or w1th a slgnlflcant dependent or lndependent other. Al so, ln 275 of the total of 395 charts, the questlon about major Ilfe changes was not answered; thls lnformatlon ls crltlcal ln plann1ng hospltal dlscharges for ail patients, especlally older pat lents. 2." Analy.'. 2... 1 Data from Medical Chart. The focus of the analysls was to compare t1mlng of SOCial work lnterventlons, LOS, and readmlsslon rates, before and after the lntroductlon of the lnterdlsclpllnary dlscharge plannlng rounds, that 1 s, between the 1990 and 1992 sampi es. The deslgn was a year-to-year comparlson; thls procedure was lntroduced because there was no posslblilty of havlng randomly asslgned sampi es. The flrst step ln the analysls was ta establlsh the equlvalence of the samples based on ail of the control varlables--"that the treatment and comparlson groups are sa slmllar on measures belleved related ta the outcome that they can be vlewed às equlvalent except for the treatment (and ail unmeasured varlables)" (Julnes Sc Mohr,

25 1989, p. 635). The control varlables Included those whlch descrlbed the patlent's situation pr 10r to hosp1tal1zat1on, that 1S, the demographlc, functlonal status, and slckness~related variables. Nominal (categor1cal) var1ables were crosstabulated by year, and chl-square tests of slgnlflcance calculated. Mean values of cont1nuously-scaled var1ables, such as age, wel'"e calculated for the two sampi es, and t-tests of sign1f1cance p~rformed. The second step in the analyris was to make a direct compar1son of the three dependent (outcome) var1ables for the two years. For LOS thls was done by calculat1ng me an days for the two years, with at-test for slgnif1cant d1fference; for tlmlng of social work intervent10n and readm1ss1on, by crosstabulat1on and ~alculatlon of chl-square (see Appendix 2). The thlrd step, for each of the three dependent var1ables, was to determlne the effect of year, controll1ng for relevant demographlc and slckness-related variables. Th1S was c10ne by multlple regresslon analysls, in three steps: 1. Backward stepwlse regress10ns uslng ail of the demographic and lilness-related varlables, were performed to establ1sh a short 11St of pred1ctors that appeared to have a slgn1flcant effect on each dependent variable; thls was done wlthout year as a variable. Each of the three stepwlse procedljres

26 was termlnated at the step that Ylelded the maximum adjusted R 2. 2. Block regresslons were then performed for each dependent varlable to examine the effect of year when added to the best model obtalned ln the stepwise regyesslon. 3. ThIS was followed by a path analysls to examine patterns of causatlon among the control variables (demographlc, functlonal status and slcknessrelated) that were expected to have an effect on the three dependent variables. ThIS procedure followed the recommendat1ons of Julnes and Mohr (1986): Once the declslon ls made that the groups are "equlvalent" on the bas1s of a no-d1fference f1nd1ng, the 1nformat1on from the control var1ables ls typ1cally d1scarded. Thls d1sregard of valuable 1nformat1on ls unn~cessary and unfortunate 1t ls best to use th1s 1nformatlon about d1fferences ln the analys1s for example, as lndependent variables ln a mult1ple regress10n equatlon (p. 636). 1 ls a graph1c presentation, of the hypotheses about relatlonshlps between the control and dependent variables, that gu1ded the analysis. The causal model examined postulates that gender, age, and llvlng sltuat10n affect pat1ent's funct lonal status (degree of physlcal ab1llty or lmpa1rment), Wh1Ch 1nfluences the type (emergency, semi-uygent or nonurgent) and nature (medlcal or surg1cal) of admission, and dlagnosls, and that these ln turn have an effect on the t1mlng of soc1al work InterventIon, LOS, and readm1ss1on. Whether or not 1nterd1sclpl1nary d1scharge plannlng rounds had an lmpact on the outcome varlables

Figure l.--relationship Between Variables: Causal Model Interdlsciplinary discharge planning rounds Hypothesis Outcome SW mtervention Control variables Length ofstay Age Type of admission (emergency or Dot) Readnllsslon 1\) --..J Gender I~ivin~ ~SltuatJon 1 1-1l> r=0nal l----t> l'nature.of C~ --l: admission (Medicall surgical) i idiagnosis

28 was the focus of thls study. To make the regresslon analysis possible, certain data had to be manlpulated: 1. Tlme ta Readmlsslon: Data collection occurred three months after the latest possible dlscharge date for the 1992 Sample, therefore the longest possible tlme lapse between dlscharge and readmlsslon for the 1992 Sample was 90 days. The timing of the data collection thus allowed for a smaller number of readmisslons from the 1992 Sample than from the 1990 Sample. To make the samples comparable, a new ordinal variable was created. Tlme to r.admlsslon was recoded into categories; a patient who was not readmitted in the available tlme was coded ln the last category together with readmissions over 90 days after dlscharge. Details of the procedure are glven ln Appendlx 2. 2. Social work Intervention: The problem here was to find a way to deal statistically with patients who were not referred to social work at ail; to omit them from the analysis would represent an important 10s5 of information. Agaln values were recoded to form an ordinal scale, with patients who did not recelve social work Intervention grouped wlth patients who were referred to social work 90 days after admission CAppendix 2).

29 3. Diagnosis (Expected LOS): A major technlcal problem was presented by the fact that the maln determinant of LOS ls the nature of the patlent's illness. A way had to be found of controlli.ng for diagnosls ln the year-to-year comparlson. Th 1 S ~Jas done by using standard CMG classlflcatlons to establlsh an expected LOS (days) for each patlent, based on that patient's dlagnosis (see Appendlx 2). 4. Sever a 1 ot her variables (e.g., funct ional status, type and nature of admission) also had to be recoded for use in the regresslon analyses (Appendlx 2). Ali data were analyzed utillsing the Statistlcal Package for the Social Sciences (SPSS). 2.4.2 Data fro. Di.charg. Planning Ca..ttt.. "inut Qualitative research methods were a1so incorporated into this study. Wh.n it was discovered that there were no slgnlfic.nt dlfferences, ln the expected dlrect7.on, in the timing of soc lai work lntervention, LOS, and readmlsslon rates between the 1990 and 1992 samp1es (see sect ions 3. 1 to 3.3 below), an examlnation of the dlscharge planning process at the Hospi.tal was undertaken, through a revlew of Discharge Planning Committee minutes (OPCM), to look for possible

30 explanations. ror thls study, the minutes of the ope meetings from Oecember 1990 to October 1992 were studled to better understand the actual procedures and effects of the dlscharge planning rounds. ThIS procedure follows the recommendations of other researchers. Knafl and Howard (1984), suggest that qualitative research "serves as an adjunct to studies that are primarlly quantitative ln nature" (p. 18) Wilson (1985) stated, "Quai itat ive anecdotes are often used to answer 'why' and 'how' questions associated with quantltat1ve study findings" (p. 399). Also, Steckler (1989) found qualitative methods useful ln identlfying the presence of a Type III error, defined as the "failure to implement a programmatic intervention completely or adequately" Cp. 118). 2.4.3 Data fra. Int.rvl.w. According to Berg (1989), "the interview is an especially effect1ve method of collecting information for certain types of research questions". Also, Berg stated that "particularly when investigators are interested in understanding the perceptions of partic1pants, or learning how participants come to attach certain meanings to phenomena or events, interviewing becomes a use fui means of access" (p. 19).

31 An Interview guide, WhlCh lncluded categories that emerged from the study of OPC mlnutes, was developed and used for semistructured lntervlews wlth four members of Hospital staff (a physiclan, a nurse, and two social workers> who were selected on the basls of the followlng criteria: 1. They were ail working at the Hospital durlng 1990 and 1992. 2. They either attended the weekly discharge planning rounds regularly or particlpated in discussions at the DPC meetings; the social workers participated at both, whlle the physlclan attended only DPC meetings and the nurse attended only rounds. 3. They ail had direct contact wlth patients. The nurse and one of the social workers held supervisory positions; the physlclan was a senior administrator. The four one-hour interviews were audio recorded, transcribed, and content analyzed. The data gathered from the content of the interviews was then organlzed and lncorporated with related findings from the study of the OPC minutes. lnto how some Ali four key lnformants contributed inslght disciplines regarded the rounds, changlng patient attitudes, and also into the inconslstencies in discharge planning procedures.

32 3. Finding. 3.1 D çription of 'hm Sampl. The study sample comprlsed the medlcal charts of 395 dlscharged medlcal and surglcal, acute care patlents aged 65 and over: 182 pat lents in 1990, (before discharge plannlng rounds) and 213 pat lents in 1992 (after the rounds were establlshed). Table 1 shows demographic varlables; the 1990 and 1992 Samples were slmllar in most respects, with mean ages of 77.9 and 78.3 respectlvely. The only slgnificant difference between samples was ln livlng arrangements; a signiflcantly hlgher percentage of pat lents ln the 1992 Sample were admitted from a sheltered environment, such as a nurslng home or foster home. Table 2 shows status prlor to hospitalizatl0n, by year. There were twq slgnificant differences: the 1992 Sample had more patients recelvlng homecare services before hospltalizatlon than did the 1990 Sample. AIso, a higher percentage of p,ltients in the 1992 Sample had experienced recent 11fe changes prior to hospltallzatlon. Information about such 11fe changes was av.ilable trom 94 patient charts in the 1992 Sample, compared to only 23 charts for the 1990 Sample.

33 Table 1.--Demographlc Varlabies, by Vear 1990 Sampie (n=192) 1992 Sample (n=213) ri ('l.) tf ('l.) &llnd.r Male 66 36.7 73 34.3 remale 114 63.3 140 65.7 Misslng 2 0 Ag. Cat-vory 65-74 63 35.2 B3 39.2 75-84 B6 48.0 81 38.2 85 and over 30 16.8 48 22.6 Missing 3 1 Plac. of BArth Quebec 83 45.9 115 54.5 Other Canadian province 19 10.5 19 9.0 Great Bntain 5 2.8 8 3.8 Eastern Europe 33 18.2 25 11.8 Other European country 11 6.1 16 7.6 w.stern ASla and Arab countries 5 2.8 6 2.8 C.ribbean 2 1.1 3 1.4 Other countrles 23 12.7 19 9.0 Missing 1 2 Civil atatu. Wido~ed, dlvorced separated 95 54.9 96 46.6 Single 16 9.2 30 14.6 Marned 62 35.8 BO 38.8 Mis.lng 9 7 bic atatu. Not employed 163 94.8 192 93.2 Elllployed 9 5.2 14 6.8 Missing 10 7

34 Table 1.--Continued 1990 Salllple (n=182> 1992 Sample (n=213> ri (X> ri (X> Occupation Engaged in whlln Ellploy.d Servlce-related 44 24.4 40 19.1 Professlonal 12 6.7 13 6.2 Sales 6 3.3 10 4.8 Managelllent or admlolstrat ion 13 7.2 11 5.3 Not indlcated 105 58.3 135 64.6 Misslng 2 4 Living Arrang...,t l Wlth lnd.pendent slgnl ficant other 83 46.1 86 40.6 WI th dependent signi ficant other 10 5.6 11 5.2 Lives alone 67 37.2 66 31.1 LIves in shelt.r.d setting 12 6.7 38 17.9 Not clear 8 4.4 11 5.2 MIssing 2 1 Religion CathollC 95 53.4 115 54.0 Protestant 32 18.0 31 14.6 Jewlsh 27 15.2 42 19.7 Christian Orthodox 15 8.4 13 6.1 Buddhlst or Moslell 1.6 3 1.4 Not lndicated 8 4.5 9 4.2 Missing 5 0 Note. Percentages liiay not always add to 100 due to rounding.'fech. 1 Chi-square (4, n= 392> = 11.57, Q<.05.

35 Table 2.--Status Prlor to Hospltallzatlon, by Year 1990 Sample (n=182) 1992 Sample (n=213) N (ï.) N (ï.> FunetionAl statu. (Di.abU iu.. > Moblilty problems 25 14.1 56 26.7 None lndlcated Hearlng/vlsual 64 24 36.2 13.5 63 23 30.0 11.0 Incontinent 5 2.8 1.5 Unusual behavlour 1 4 2.3 5 2.4 Alcohol/drug abuse 3 1.7 4 1.9 Multlele eroblems Two of the above 34 19.2 40 19.0 More than two 11 6.2 15 7.1 More than thn?e 7 4.0 3 1.4 Servie.. rec:.i v.j None lndlcated 118 65.2 96 45.1 Not appllcable 10 5.5 34 16.0 One service 8 4.4 29 13.6 More then one 17 9.4 41 19.2 Services recelved--type and number unknown 28 15.5 13 6. 1 Mlsslng 1 0 Yicti.. of Abu.. Ves 10 5.5 12 5.6 No 171 '94.5 201 '94.4 Mlsslng 1 0 Ev..,ta/Olang.J Not lndlcated 158 87.3 117 55.5 No 6 3.3 65 30.8 Ves 17 9.4 29 13.7 T:z:ee of change Loss of fr lendl relative 6 3.3 10 4.7 Move to a 'home' 4 2.2 6 2.8 Other change 7 3.'9 13 6.2 Mlsslng 1 2 Note. Percentages may not always add to 100 due to roundlng effects. Includes confusion and forgetfulness. 2 Chi-Square (4, n = 394) = 40.36, 2<.0001. 3 Chi-Square (4, ~ - 392) = 56.38, ~<.0001.

36 Table 3 shows admission Information by year, and Table 4 shows hospltallzation and dlscharge Information. The two samples were slmllar in type of admission, prevlous admission history, and nature of admission (medlcal or surglcal). No slgnlflcant dlfferences were found between years ln expected LOS (1990 and 1992 means were 8.92 and 8.63 respectlvely), or ln the number of patients referred to as non-compilant ln the medical charts (Table 4). A slgnlficantly higher percentage of patients in 1992 than ln 1990, howrver, were dlscharged to sheltered settings, such as foster homes or nursing homes (more were also admltted from these--see Table 1), returned to Emergency for reasons related to their previous hospltalizatlons, and recelved homecare se~vices after dlscharge. The dlfferences between the two samples is more a reflection of the patients' lncoming status, than of dlscharge planning outcomes. 3.2 EfflCt. of the Di.charg_ Planning Roynd. Table 5 shows a comparison of outcome variables for the two years. Mean length of tlme before patients recelved social work intervention was slmilar; in 1990, soclal work lnterventlon began an average 8.27 days after admlssion, and ln 1992, 8.91 days. Mean LOS was lower

37 Table 3.--Admission Information, by Vear 1990 Sample ri (n=182) ('1.) 1992 Sampi e t'! (n=213) (%) Type of Ad.t ion Emergency Se/lli-emergency Non-emergency t1lsslng 109 8 52 13 64.5 4.7 30.8 149 12 42 10 73.4 5.9 20.7 PrllYiaus Ad.issians rirst admission to Hospltal Admitted froftl long term care 1 this 69 2 39.0 1. 1 5B 0 27.6 0.0 Readmi Ued 2 within 1 week SII.. e di Agnos i 5 3 Other dlagnosis 4 0 2.3 0.0 4 1 1.9.5 R.admitt~ wi~hin 1 IIOnth Salle diagnosls Other diagnosis Readmitted within 1 v.ar Sa... diagnosis Other diagnosis Readmitted after 1 yeilr 6 1 26 9 58 3.4 6.6 14.7 5.1 32.8 7 5 37 21 74 3.3 2.4 17.6 10.0 35.2 No Adllission informatlon Hissinv 2 3 1.1 3 3 1.4 Natur. of Ad.issian Hedical Surgiea1 Hissing 100 72 10 58.1 41.9 129 76 B 62.9 37.1 1 Classi fication ehangltd frofll long ter,. to aeuh care. 2 Read/llitted after being dlscharged fra. the s... Hospital 1ess than one week ago. 3 Current diagnosis was related to the dlagnos15 durlng previous hospitalizatlon.

Table 4.--Hospitallzatlon and Discharge InformatIon, by Vear 38 1990 Sample (n=182) 1992 Sample (n z 2t3) ri (Y.) ri (Yo) ExpllC tlkl LOS ~ 2 days 22 12.8 21 10.2 3-5 days 3S 20.3 39 18.9 6-8 days 38 22.1 51 24.8 9-12 days 42 24.4 58 28.2 13-17 days IS 8.7 21 10.2 18-24 days 16 9.3 13 6.3 25-30 days 2 1.2 3 1.5 31-35 days 2 1.2 0 0.0 1"I1ss1ng 10 7 Prabl_ Pat i..,t COIllpI iant 164 90.6 195 91.5 Not conpllant with: Hospital routine 7 3.9 10 4.7 Other aspect of hospl talization 7 3.9 4 1.9 r10re th.n one aspect of hospit.l iz.tion 3 1.7 4 1.9 l"iisslng 1 0 o..t inat ion t With independant signl hc.nt other 79 43.9 73 34.4 Wi th dependant slgni ficant other 6 3.3 8 3.8 Ho"e alone 50 27.8 47 22.2 To sheltered settlng 40 22.2 68 32.1 Not clear 5 2.8 16 7.5 Mlsslng 2 1