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Planning for a Safe Discharge: More Than a Capacity Evaluation.
Serena P Wong1, Neema Sharda1, Kahli E Zietlow1
1Department of Medicine, Duke University Medical Center, Durham, North Carolina.
Journal of the American Geriatrics Society
|January 7, 2020
Summary
Navigating discharge for older adults with complex needs requires balancing patient autonomy with facility recommendations. A new framework promotes interprofessional collaboration and patient support to maximize independence at home.
Area of Science:
- Geriatrics
- Healthcare Management
- Patient-Centered Care
Background:
- Discharge decision-making for hospitalized older adults is complex, involving assessments and resource coordination.
- Providers face ethical dilemmas when patient wishes conflict with recommendations for skilled nursing facilities due to complex care needs.
- Patient autonomy and shared decision-making are key values for healthcare providers.
Purpose of the Study:
- To present a discharge decision-making framework for hospitalized older adults.
- To address the ethical and professional challenges faced by providers in discharge planning.
- To support maximizing independence for vulnerable older adults.
Main Methods:
- Describing a framework focused on interprofessional evaluation and management.
- Emphasizing longitudinal follow-up and education for patients and families.
- Highlighting information synthesis, goal elicitation, and community resource identification.
Main Results:
- The described framework aids in navigating complex discharge decisions.
- It facilitates better coordination between healthcare teams, patients, and families.
- The approach aims to enhance patient independence and align care with patient preferences.
Conclusions:
- A structured, interprofessional approach can improve discharge planning for older adults.
- Supporting patient and family involvement is crucial for successful home transitions.
- This framework helps providers uphold patient autonomy while managing complex care needs.
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