Adaptation and implementation of a patient-centered tool for improved discharge planning for seniors in hospital


Seniors and their caregivers usually encounter challenges and even serious risks during the period of transition between hospitalization and home return. About 1 in 3 patients aged 65 and over who are discharged home following medical admission will be readmitted or will return to the emergency department (ED) within 3 months of their discharge. This readmission rate can be reduced by improving the education of the patient and their caregiver before discharge.
Our team proposed a solution based on the scientific literature, a technology assessment (ETMISSS) and the needs expressed by the nursing staff, patients and caregivers: a simple sheet (the Patient-centered discharge plan (PCAP in French)) allows staff and the patient / caregiver to record key information that is transmitted verbally during discharge planning, while structuring the transfer of information and education of the patient / caregiver.
The objectives of this study were to assess the feasibility and acceptability of offering the PCAP intervention, and to explore the effectiveness of using PCAP to reduce the rate of return to EDs and readmission in both targeted hospitals.
We have completed the recruitment and collection of data from patients and caregivers (before and after implementation) and are currently collecting data from health professionals on participating units to better describe the implementation process. The results and final tool will be disseminated across Quebec to allow other CISSS / CIUSSS to benefit from the work accomplished and lessons learned. The results will also be published in a scientific journal.