Background
Discharge planning is a routine feature of health systems in many countries. The aim of discharge planning is to reduce hospital length of stay and unplanned readmission to hospital, and to improve the co-ordination of services following discharge from hospital.This is the third update of the original review.

Objectives
To assess the effectiveness of planning the discharge of individual patients moving from hospital.

Search methods
We updated the review using the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE, EMBASE, CINAHL, the Social Science Citation Index (last searched in October 2015), and the US National Institutes of Health trial register (ClinicalTrials.gov).

Selection criteria
Randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to individual participants. Participants were hospital inpatients.

Data collection and analysis
Two authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies according to patient groups (elderly medical patients, patients recovering from surgery, and those with a mix of conditions) and by outcome. We performed our statistical analysis according to the intention-to-treat principle, calculating risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data was not possible because of differences in the reporting of outcomes, we summarised the reported data in the text.

Main results
We included 30 trials (11,964 participants), including six identified in this update. Twenty-one trials recruited older participants with a medical condition, five recruited participants with a mix of medical and surgical conditions, one recruited participants from a psychiatric hospital, one from both a psychiatric hospital and from a general hospital, and two trials recruited participants admitted to hospital following a fall. Hospital length of stay and readmissions to hospital were reduced for participants admitted to hospital with a medical diagnosis and who were allocated to discharge planning (length of stay MD − 0.73, 95% CI − 1.33 to − 0.12, 12 trials, moderate certainty evidence; readmission rates RR 0.87, 95% CI 0.79 to 0.97, 15 trials, moderate certainty evidence). It is uncertain whether discharge planning reduces readmission rates for patients admitted to hospital following a fall (RR 1.36, 95% CI 0.46 to 4.01, 2 trials, very low certainty evidence). For elderly patients with a medical condition, there was little or no difference between groups for mortality (RR 0.99, 95% CI 0.79 to 1.24, moderate certainty). There was also little evidence regarding mortality for participants recovering from surgery or who had a mix of medical and surgical conditions. Discharge planning may lead to increased satisfaction for patients and healthcare professionals (low certainty evidence, six trials). It is uncertain whether there is any difference in the cost of care when discharge planning is implemented with patients who have a medical condition (very low certainty evidence, five trials).

Authors' conclusions
A discharge plan tailored to the individual patient probably brings about a small reduction in hospital length of stay and reduces the risk of readmission to hospital at three months follow-up for older people with a medical condition. Discharge planning may lead to increased satisfaction with healthcare for patients and professionals. There is little evidence that discharge planning reduces costs to the health service.

/pdf/discharge-planning-from-hospital-3abc89cqh3.pdf

Discharge planning from hospital

Background
In people with chronic obstructive pulmonary disease (COPD) there is considerable variation in symptoms, limitations and well-being, which often complicates medical care. To improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations, a multidisciplinary program including different elements of care is needed.

Objectives
To evaluate the effects of integrated disease management (IDM) programs or interventions in people with COPD on health-related QoL, exercise tolerance and number of exacerbations.

Search methods
We searched the Cochrane Airways Group Register of trials, CENTRAL, MEDLINE, EMBASE and CINAHL for potentially eligible studies (last searched 12 April 2012).

Selection criteria
Randomized controlled trials evaluating IDM programs for COPD compared with controls were included. Included interventions consisted of multidisciplinary (two or more health care providers) and multi-treatment (two or more components) IDM programs with a duration of at least three months.

Data collection and analysis
Two review authors independently assessed trial quality and extracted data; if required, we contacted authors for additional data. We performed meta-analyses using random-effects modeling. We carried out sensitivity analysis for allocation concealment, blinding of outcome assessment, study design and intention-to-treat analysis.

Main results
A total of 26 trials involving 2997 people were included, with a follow-up ranging from 3 to 24 months. Studies were conducted in 11 different countries. The mean age of the included participants was 68 years, 68% were male and the mean forced expiratory volume in one second (FEV1)% predicted value was 44.3% (range 28% to 66%). Participants were treated in all types of healthcare settings: primary (n = 8), secondary (n = 12), tertiary care (n = 1), and in both primary and secondary care (n = 5). Overall, the studies were of high to moderate methodological quality.

Compared with controls, IDM showed a statistically and clinically significant improvement in disease-specific QoL on all domains of the Chronic Respiratory Questionnaire after 12 months: dyspnea (mean difference (MD) 1.02; 95% confidence interval (CI) 0.67 to 1.36); fatigue (MD 0.82; 95% CI 0.46 to 1.17); emotional (MD 0.61; 95% CI 0.26 to 0.95) and mastery (MD 0.75; 95% CI 0.38 to 1.12). The St. George's Respiratory Questionnaire (SGRQ) for QoL reached the clinically relevant difference of four units only for the impact domain (MD -4.04; 95% CI -5.96 to -2.11, P < 0.0001). IDM showed a significantly improved disease-specific QoL on the activity domain of the SGRQ: MD -2.70 (95% CI -4.84 to -0.55, P = 0.01). There was no significant difference on the symptom domain of the SGRQ: MD -2.39 (95% CI -5.31 to 0.53, P = 0.11). According to the GRADE approach, quality of evidence on the SGRQ was scored as high quality, and on the CRQ as moderate quality evidence. Participants treated with an IDM program had a clinically relevant improvement in six-minute walking distance of 43.86 meters compared with controls after 12 months (95% CI 21.83 to 65.89; P < 0.001, moderate quality). There was a reduction in the number of participants with one or more hospital admissions over three to 12 months from 27 per 100 participants in the control group to 20 (95% CI 15 to 27) per 100 participants in the IDM group (OR 0.68; 95% CI 0.47 to 0.99, P = 0.04; number needed to treat = 15). Hospitalization days were significantly lower in the IDM group compared with controls after 12 months (MD -3.78 days; 95% CI -5.90 to -1.67, P < 0.001). Admissions and hospital days were graded as high quality evidence. No adverse effects were reported in the intervention group. No difference between groups was found on mortality (OR 0.96; 95%CI 0.52 to 1.74). There was insufficient evidence to refute or confirm the long term effectiveness of IDM.

Authors' conclusions
In these COPD participants, IDM not only improved disease-specific QoL and exercise capacity, but also reduced hospital admissions and hospital days per person.

/pdf/integrated-disease-management-interventions-for-patients-1i7wsdr9ug.pdf

Integrated disease management interventions for patients with chronic obstructive pulmonary disease

Objectives
To determine the effect of integrating informal caregivers into discharge planning on postdischarge cost and resource use in older adults.

Design
A systematic review and metaanalysis of randomized controlled trials that examine the effect of discharge planning with caregiver integration begun before discharge on healthcare cost and resource use outcomes. MEDLINE, EMBASE, and the Cochrane Library databases were searched for all English-language articles published between 1990 and April 2016.

Setting
Hospital or skilled nursing facility.

Participants
Older adults with informal caregivers discharged to a community setting.

Measurements
Readmission rates, length of and time to post-discharge rehospitalizations, costs of postdischarge care.

Results
Of 10,715 abstracts identified, 15 studies met the inclusion criteria. Eleven studies provided sufficient detail to calculate readmission rates for treatment and control participants. Discharge planning interventions with caregiver integration were associated with a 25% fewer readmissions at 90 days (relative risk (RR) = 0.75, 95% confidence interval (CI) = 0.62–0.91) and 24% fewer readmissions at 180 days (RR = 0.76, 95% CI = 0.64–0.90). The majority of studies reported statistically significant shorter time to readmission, shorter rehospitalization, and lower costs of postdischarge care among discharge planning interventions with caregiver integration.

Conclusion
For older adults discharged to a community setting, the integration of caregivers into the discharge planning process reduces the risk of hospital readmission.

/pdf/caregiver-integration-during-discharge-planning-for-older-2i5w1ibk2g.pdf

Caregiver Integration During Discharge Planning for Older Adults to Reduce Resource Use: A Metaanalysis

Transitions in care from hospital to primary care for older patients with chronic diseases (CD) are complex and lead to increased mortality and service use. In response to these challenges, transitional care (TC) interventions are being widely implemented. They encompass education on self-management, discharge planning, structured follow-up and coordination among the different healthcare professionals. We conducted a systematic review to determine the effectiveness of interventions targeting transitions from hospital to the primary care setting for chronically ill older patients.. Randomized controlled trials were identified through Medline, CINHAL, PsycInfo, EMBASE (1995–2015). Two independent reviewers performed the study selection, data extraction and assessment of study quality (Cochrane “Risk of Bias”). Risk differences (RD) and number needed to treat (NNT) or mean differences (MD) were calculated using a random-effects model. From 10,234 references, 92 studies were included. Compared to usual care, significantly better outcomes were observed: a lower mortality at 3 (RD: −0.02 [−0.05, 0.00]; NNT: 50), 6, 12 and 18 months post-discharge, a lower rate of ED visits at 3 months (RD: −0.08 [−0.15, −0.01]; NNT: 13), a lower rate of readmissions at 3 (RD: −0.08 [−0.14, −0.03]; NNT: 7), 6, 12 and 18 months and a lower mean of readmission days at 3 (MD: −1.33; [−2.15, −0.52]), 6, 12 and 18 months. No significant differences were observed in quality of life. In conclusion, TC improves transitions for older patients and should be included in the reorganization of healthcare services.

Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review

Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.

pdf/interventions-to-promote-early-discharge-and-avoid-ybetwyqxul.pdf

Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review.

Background. Discharge planning is key element in the healthcare continuum that seeks to bridge the gap between hospital and patient home environment. As limited data is available for COPD, we conceived this study to determine the effectiveness of discharge coordinator intervention in reducing the risk for COPD hospitalisation. Methods. This was a randomized, controlled trial that compared discharge coordinator intervention with usual care. Patients were enrolled within 48 hours following admission due to COPD exacerbation. Discharge coordinator intervention included educational and self-management sessions with patients and caregivers and liaison with health and social care providers in patient home environment. Patients in control group received standard management. Results. Of the 253 eligible patients (71±9 years, 72% men, 87% GOLD III/IV), 118 were assigned to intervention and 135 to usual care group. During follow-up of 180 days, fewer patients receiving intervention were hospitalized due to COPD (14% vs 31%, p=0.002). In time to event analysis, intervention was associated with lower rates of COPD hospitalisations (p=0.001). Cox model of proportional hazards adjusted for sex, age, GOLD stage, heart failure, cancer, and long term oxygen treatment demonstrated that intervention reduced risk of COPD hospitalisation (hazard ratio 0.43, 95% confidence interval 0.24-0.77, p=0.002). Conclusions. Among patients hospitalized for COPD exacerbation, discharge coordinator intervention reduced COPD hospitalisations. Hospital management programs should consider discharge planning to improve outcome in patients with COPD.

https://erj.ersjournals.com/content/erj/40/Suppl_56/P2895.full.pdf

Discharge coordinator intervention prevents hospitalisations in patients with COPD: A randomized controlled trial

Mini nutritional assessment, body composition, and hospitalisations in patients with chronic obstructive pulmonary disease

Discharge coordinator intervention prevents hospitalizations in patients with COPD: a randomized controlled trial.

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Discharge coordinator intervention prevents hospitalisations in patients with COPD: A randomized controlled trial

Mini nutritional assessment, body composition, and hospitalisations in patients with chronic obstructive pulmonary disease

Discharge coordinator intervention prevents hospitalizations in patients with COPD: a randomized controlled trial.