Addressing patientAddressing patient’’s s psychosocial needs during the psychosocial needs during the discharge planning processdischarge planning process

Stephanie CHUIStephanie CHUICHAN Kit HoiCHAN Kit Hoi

Kylie KAMKylie KAMTanyTany KWONGKWONG

Ellen KUEllen KUStirlingStirling LAULAUMaggie TSEMaggie TSE

30 October 2010

Hosp. D(COPD)

What are the psychosocial needs of

patients upon discharge?

Clients OrganizationProviders

Care CoordinationShared decision making

Multidisciplinary teamwork

Reflect own practices

Listen to discharge patient & carer’s voice

Team Reflection: What do we learn

Hosp. A(Mental)

Hosp. B(Stroke)

Hosp. C(OBS-

Postnatal)Hosp. E

(Ca Breast)

Hosp. F(PaedOnco)

Engaging Stakeholders

Reflection on own practices in 6 local hospitals (4 Public Hospitals, 2 Private Hospitals)

• Reflection on own practices in 6 local hospitals

Carve; Smith; Antoni; Petronis, & Weiss & Derhagopian, (2005).

• Simple discharge make up 80% of most hospital discharge (Lee, 2004)

• According to the statistics of 2008, total hospital discharge was 1,590,616. (Hospital Statistical Report 2008-2009). 20% of which accounted for 318,123 discharge of 2008.

Hospital A B C D E F

SocialEmotional x x

MentalSpiritual x x

Behavioral x x

AimsTo improve the process for discharge in addressing the psychosocial needs of patients and their caregivers for ongoing care

Objectives1. A holistic framework will be developed for

discharge planning and on-going care2. Comprehensive strategies will be formulated to

ensure better practice for discharge planning and on-going care

Patient Experience

Workshop on addressing patientsWorkshop on addressing patients’’psychosocial needs during hospitalization psychosocial needs during hospitalization

& discharge process& discharge process

•• Date: 20/4/2010 Time: 10:00Date: 20/4/2010 Time: 10:00--12:0012:00•• Venue: Video Conference Hall, 4F, Block Venue: Video Conference Hall, 4F, Block

C, AHNHC, AHNH•• Speakers: Chan Kit Hoi, Stephanie Chui, Speakers: Chan Kit Hoi, Stephanie Chui,

Ellen Ku, Ellen Ku, TanyTany KwongKwong, Kylie , Kylie KamKam•• Facilitators: Facilitators: StirlingStirling Lau & Maggie Lau & Maggie TseTse•• No. of participants: 27 (from 6 hospitals)No. of participants: 27 (from 6 hospitals)

Client

Discharge Risk AssessmentEstimated Date of DischargeCommunicationEvaluation & Monitoring

Holistic Discharge Planning Framework

Personalized Care Planning in Hospital DischargeJOINT DECISION

WHOLE SYSTEM COMMISSIONING

Shared decision Care pathways Personalized care

Shared Decision on needs and risks

Holistic Discharge Planning Strategies:

1.Start on admission2.Designated coordinator3.Mutually agreed EDD4. Review pre-discharge checklist 5. Multidisciplinary Case conference 6. Follow-up7. Post discharge audit

Evaluation on the effectiveness of the project

• One week post discharge:– Client satisfaction (95% satisfied; 5% comment on

waiting time for the logistics process)• Quarterly Report on:

– Phone enquiry after discharge around 1%– Readmission within 28 days < 2%

• Knowledge check on “Self care ability” on the first follow up improved from 60% to 85%

Sustainability1. Disseminate the report at local/international

conference by Jan 20112. Publish report in professional journal by Jan

20113. Recommend and participate in the nursing

council for professional & policy development

4. Compare strategy with international standard such as NHS, ACHS

5. Bench marking: across hospitals

Group Reflection

References:1. Carver, C.; Smith, R.; Antoni, M.H.; Petronis, M.V. & Weiss, S. & Derhagopian, R. P. (2005). Optimistic

Personality and Psychosocial Well-Being During Treatment Predict Psychosocial Well-Being Among Long-Term Survivors of Breast Cancer. Health Psychology. Vol. 24(5). P. 508–516.

2. Jespersen, S.; Chong, T.; Donegan, T.; Gray, K.; Kudinoff, T.; McGain, L. & Gant, D. (2009). Reflections on facilitated discharge from a mental health service. Australian Psychiatry. Vol 17(3). P.195-201.

3. Lo, M.; Svalenius, E.C. & Persson, E.K. (2006). Factors that influence first-time mothers’ choice and experience of early discharge. Scandinavian Journal of Caring Science. Vol. 20. P. 323–330.

4. Pigott, C.; & Pollard, A.; Thomson, K. & Aranda, S. (2009). Unmet needs in cancer patients: development of a supportive needs screening tool (SNST). Support Care Cancer. Vol. 17. P.33–45.

5. Portillo, M.C.; Corcho´n, S. Lo´pez-Dicastillo, O. & Cowley, S. (2009). Evaluation of a nurse-led social rehabilitation programme for neurological patients and carers: an action research study. International Journal of Nursing Studies. Vol. 46. P.204–219.

6. Supportive Needs Screening Tool. (2009). Peter MacCallum Cancer Centre Supportive Needs Screening Tool. Patient Details & Referral Form. (2009). Peter MacCallum Cancer Centre

7. Thewes, B.; Butow, P. &Girgis, A. & Pendlebury, S. (2004). Assessment of Unmet Needs Among Survivors of Breast Cancer. Journal of Psychosocial Oncology. Vol. 22(1). P.51-73.

8. Williams, C. (2003). Discharge Planning Process on a General Psychiatry Unit. Social Work in Mental Health, Vol. 2(1). P.17-31.