Discharge Planning Advisor: Research to separate DP outcome, process goals 

PhD candidate fine-tuning new screen

After working 15 years as a discharge planner and earning masters’ degrees in nursing and clinical research, there’s an incongruity that Diane Holland, RN, MS, MBS, who is now pursuing a PhD through the doctoral program at the University of Minnesota School of Nursing in Minneapolis, would like to resolve.

"One of the [discharge planning issues] I’ve always been impressed with," says Holland, "is the confusion that I’ve had related to outcome goals being the same as process goals.

"Discharge planning is accepted to be a process, but if you consider the goals of the traditional discharge planning screen, they’re all measured against the goals of the outcome of the entire screening process," she points out.

With that perceived disconnect in mind, Holland is making a distinction between process goals and outcome goals in her doctoral research.

"Where the [position espoused in] discharge planning literature is to have the outcome of screening as disposition at discharge, length of stay, readmission, etc.," she explains, "I’m instead looking at each step of the process."

Holland says she is working to develop a screen that identifies, early in their stay, adult patients who will use specialized hospital discharge planning services "based on the goal of screening to assist in the next step of assessment."

"It is mandated by Medicare that hospitals identify early in their stay people who would suffer adverse health effects without additional discharge health evaluation," Holland points out. But she notes that in working on the screen, she has been "really unable to distinguish the goal of the screening or the outcomes associated with the screening from the goals of the entire discharge process.

"In terms of rethinking the discharge process," she goes on, "it’s very difficult in the first place to really link discharge planning uniquely to patient outcomes of hospitalization. It’s even tougher to be able to tease out any of the individual steps in the process in terms of their unique contribution to process or outcomes."

With her screen, Holland says, the idea is to screen patients to determine in a timely manner whether they will use additional hospital resources. Looking at readmission and length of stay to judge the effectiveness of the process "really misses the mark," she adds.

So far, she has identified four variables — advanced age, prior living status, disability score, and self-reported walking limitation — that determine with "reasonable sensitivity and specificity" those who will use additional resources, Holland says. "All [the variables] are easy for a nurse or health care provider to assess."

Patients who had low scores on the screen yet still used additional discharge planning services, she hypothesizes, are "externally motivated in terms of health needs." With that in mind, she is adding another variable — "health motivation" — to see if it improves the screen’s effectiveness.

Those who scored low on the screen — meaning they didn’t match the four original variables — but still needed extra help at discharge "appeared to be people who didn’t seem able to engage in the discharge planning process," Holland says. "They didn’t feel it was their responsibility to meet their continuing care needs, so they didn’t even want to participate in their own discharge planning."

As an example, she mentions a young woman who flew to Rochester to receive care at the Mayo Clinic and, instead of flying home, wanted to drive. The young woman needed help finding a van, Holland says. "It’s the day of discharge, and there is the first note from the discharge planning service that says called to see patient with questions regarding transportation home.’

"It’s the day of discharge that finally this situation gets illuminated, when the health care team has assumed there’s no issue with this person’s ability [to arrange for the van]," she points out.

"I would have called a car rental place," Holland notes, adding that the patient’s failure to take the initiative well illustrates a concept known as "motivation in health behavior."

"Those who are intrinsically motivated tend to take it on themselves, define their health by their own standards, and look on the health care team as helpers and facilitators," she explains. "Those who are extrinsically motivated look to others."

By adding that variable, Holland expects to pick up those who will need extra help at discharge, but not for the usual reasons. "Because they’re not functionally disabled or elderly, they’re the type of patient that often slips through the cracks."

Traditionally, the outcomes being considered always are length of stay and rate of readmission, whether one is evaluating any piece of the discharge planning process or the process as a whole, she continues. "You can’t gain an understanding of the unique contribution of any one step in the process by looking at outcomes that are also assigned to every other step. When screening, you have to stand back and look at the first step and hope it leads to the next step."

It is more meaningful, Holland contends, to look at "whether or not the actual demands of the patient once [he or she] went home were planned for and met by the discharge plan," she adds. "If a family member was requested to meet some sort of continuing care need, did the family meet it, or did someone else have to pick that up? If the plan was for the son to help his father with intermittent catheterization, was that what happened, or did the plan have to be changed?"

To date, Holland notes, she has worked on her screen in only one health system with one model of discharge planning but hopes to continue this line of research in other health care settings and using other models. At present, she is preparing two manuscripts — one mostly about the screen she has developed and another that revisits the outcomes associated with both the discharge plan and the process, she adds.

"I’m working on the screen, refining the screen, and will move down the line in terms of other steps," she says, "like, say, the assessment process — how to assess meeting the person’s continuing care needs. Are there tools that will help in light of appropriate outcomes or goals as a step in the process?"

[For more information, contact:

  • Diane Holland, Doctoral Candidate, University of Minnesota School of Nursing, Minneapolis. Phone: (507) 284-4354. E-mail: quackenbush.diane@mayo.edu. Holland is interested in receiving feedback from other case managers and discharge planners, as well as identifying other health care delivery systems that might be interested in this line of research.]