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.