Outcomes of geriatric discharge planning. A quality assurance study from a geriatric rehabilitation ward

The outcome of a discharge planning procedure at a geriatric rehabilitation ward was studied with an interdisciplinary and multidimensional approach, where medical, nursing, functional and psychosocial factors were included. The patient's own expectations and attitude to functional performance and outcome were explored in an interview at the day of discharge and one month later in a follow-up telephone interview. Data were also collected from registers and medical and professional records. All the 36 patients discharged to their own homes, mostly after home assessment, or to old people's homes were followed up. The median rehabilitation stay was 30 days. Their medical status was stable over time and nursing interventions remained frequent. The functional level was unchanged for 18, and further enhanced for 10 patients. Most patients felt secure at home and received the home help they anticipated. Worries were expressed by one-third on realistic grounds, mainly medical or ideas on the accommodation. Some interventions were required and carried out by the team. Home living was as expected or better for two-thirds of the patients. The timing and the patient's situation at discharge seemed to have been well assessed, with an overall positive outcome after a month at home. Further development of practical multidimensional evaluations adapted to elderly patients is necessary in a quality assurance perspective.