fi‘. W 8‘ t t .5122??? {2”}? Earl}; at. ‘8 7% “-7 i . '. I ., I, , ,. '4, . m; 5 c. .._z. r. 5 5‘. l I}; 4‘. .v‘ ‘ A, f, 'v . i: .1 .th‘tr‘v ‘ " '. "" «4‘. , | . \ é ' 234;},"4I' figs, ’ v-l "mi ea: ‘5: 4“ $3; -. , :9 vwvvtv—v— ' ‘4‘ ’ 'y ~ #37. * L. l n l: {~13} l, . ' ‘ £5 -? “XI; my. g !"‘ .3}. . 1" fi‘ wig—.13 -~ l . a -u -‘-: 3'23}... . . a’rlf'sigkgfig‘ifi .3 {g i » ‘M’gn gibh. 5‘" \ 1. ' l" ‘ '.t§ -. " ..¢3‘.--233":‘A.:,.j(=‘“"7*“1« ‘K' Q .. 'LK s“ g 4 . '1 t N ‘ ‘ 5|! , ,. rfihk‘fi V1.“ 5 ‘ , _ '2. 5'56“ng H :Ehé‘zzk' u: . ‘ . C‘L 1;? J: V? .. a ' ‘. ‘5 $15 ‘ $.39 :‘r ‘ . ...« 3.1 . a; a {4’ n'. ' 7- . ’ . .0455"? ‘ ‘ . ‘1. 1.: ., -' . ‘ 1 . z. . ‘v‘f'ipé.3'€%‘fi3¢:§$.n\§1’c\ 5 A .~ " . r , - "Q ~ ‘ -"'\'&‘#N“ "'v' L" L" 93*? “ .fl' 4 $.35 W. ' ‘ -- . , ' ~ , 435“}, ‘5 : ‘ ‘ ' V ’ ‘ ." . u ' . I “5"": Li ' ‘2‘ ' ‘ w. ” 'f “<1 J3?! v a . . . 1."):1“? u‘yglg IUlllH‘lHHlllUIHHHIHIHISillllWlHllHllHlUW 3 1293 014099 This is to certify that the dissertation entitled DISCHARGE PLANNING AND CASE MANAGEMENT IN MICHIGAN HOSPITALS: PERCEPTIONS OF THE CONCERNS 0F ELDERLY CARDIOVASCULAR CLIENTS AND THEIR FAMILIES presented by Eleanor Smith Franey has been accepted towards fulfillment of the requirements for Ph.D. degreein Famill and Chiid Ecology %¢Mm 5 JM/ Major professor Date January 25, 1995 MSU ('3 an Affirmative Action/Equal Opportunity Institution 0-12771 LIBRARY Michigan State Unlversity PLACE ll RETURN BOX to move this chockout from your record. TO AVOID FINES mum on or baton dat- duo. DATE DUE DATE DUE DATE DUE WW1 DISCHARGE PLANNING AND CASE MANAGEMENT IN MICHIGAN HOSPITALS: PERCEPTIONS OF THE CONCERNS OF ELDERLY CARDIOVASCULAR CLIENTS AND THEIR FAMILIES By Eleanor Smith Franey A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Family and Child Ecology 1995 ABSTRACT DISCHARGE PLANNING AND CASE MANAGEMENT IN MICHIGAN HOSPITALS: PERCEPTIONS OF THE CONCERNS OF ELDERLY CARDIOVASCULAR CLIENTS AND THEIR FAMILIES By Eleanor Smith Franey Michigan’s acute care hospitals were surveyed to describe the structural, process, and outcome characteristics of discharge planning and case management programs. Discharge planners were asked to rate their perceptions of the importance of 14 concerns to elderly cardiovascular clients and their families before discharge. Analyses of variance were used to determine whether a relationship existed between discharge plannerS’ perceptions of these concerns and planned follow-up. Of Michigan’s 156 acute care hospitals, 57 participated in the mailed survey. Responding hospitals ranged from 18 to 855 beds, with a mean bed size of 184. Fifty-one percent had fewer than 100 beds. Seventeen hospitals planned to contact clients after discharge, primarily to determine discharge plan adequacy. The majority of hospitals with planned follow- up had between 25 and 99 beds. Most clients for follow-up were selected randomly from discharge planning Clients. They were contacted by telephone (53%) or by Eleanor Smith Franey both telephone and mail. Planned follow-up lasted from 8 to 14 days (38%), followed by 2 to 7 days (31%). Survey results suggested that discharge planning in Michigan’s hospitals was characterized by diversity, whether the criteria were structural. process, or outcome. Discharge planners perceived that concerns about functional status ranked highest in mean importance for both clients and families. Dietary issues were perceived to be of least concern to both groups. With the exception of general medical issues and lifestyle changes, family concerns were perceived as more important than Client concerns. Analyses of variance indicated a significant relationship between discharge planners’ perceptions of Client general medical concerns and planned follow-up (32 =. 0283), and between family communication concerns and planned follow-up (p =. 0192). Pearson correlation coefficients (r) indicated a moderate, positive relationship (r = .31 and r = .33, respectively). The study confirmed the important role of the family, and the need to engage the family in the discharge planning process. More educational preparation in family studies was suggested for discharge planners. Viewed from an ecological perspective, discharge planning was seen as a complex process dependent in part on variables and realities that are often outside the control of any of its participants. Copyright by ELEANOR SMITH FRANEY 1995 This dissertation is dedicated to Bart Franey, for his understanding and support during the development of this dissertation. ACKNOWLEDGMENTS I want to thank Sarah and Elly Franey for their love and encouragement. Also, thanks to LaRene Smith and Ruth Sedelmaier of Michigan State University for their invaluable help during the last four years. I am very grateful to all my committee members fortheir collective scholarship and their friendship. Thank you, Drs. David lmig and June Pierce-Youatt, for your participation on my dissertation committee. Special thanks to Drs. Barbara Ames and Sharon King, who were so influential throughout my graduate study. They acted as co-research directors for my dissertation and skillfully guided me through the process. Finally, the attainment of this degree would not have been possible without the vision and tenacity of my mother, Julia K. Smith. vi TABLE OF CONTENTS LIST OF TABLES ................................................ x LIST OF FIGURES .............................................. xiii Chapter I. INTRODUCTION ...................................... 1 Problem Statement .................................... 1 Purpose ....................................... 3 Scope of the Problem .................................. 3 Introduction to the Problem ........................ 3 Cardiovascular Disease and Elderly Persons .......... 5 Client and Family Concerns ........................ 7 Discharge Planning .............................. 9 Hospital-Based Case Management ................. 11 Significance ................................... 12 Theoretical Framework ................................ 16 Conceptual Definitions ................................ 21 Limitations and Assumptions ........................... 24 Research Objectives .................................. 26 Research Questions ............................. 27 II. REVIEW OF THE LITERATURE ......................... 29 Family Caregiving .................................... 29 Client and Family Concerns ............................ 32 Discharge Planning ................................... 37 Case Management ................................... 38 Case Management and Elderly Persons ................... 39 Purpose of Case Management .......................... 40 Hospital-Based Follow-up .............................. 41 Discharge Planning Follow-Up Model ............... 41 R. W. Johnson Case Management Demonstration Project ...................................... 43 vii IV. Quality of Care ...................................... 44 Quality of Care and Elderly Clients .................. 47 The Joint Commission on Accreditation of Hospitals . . . . 48 METHODOLOGY .................................... 52 Research Design ..................................... 52 The Sample ................................... 52 Data-Collection Methods ............................... 53 Background Information .......................... 53 The Instrument ................................. 53 Instrument Development ......................... 56 Study Response Rate ............................ 57 Data Analysis ....................................... 58 RESULTS .......................................... 61 Discharge Planning Survey ............................. 62 Regional Geographic Distribution ................... 62 Hospital Structure ............................... 64 Staffing ....................................... 69 Discharge Planning Process ...................... 75 Planned Follow-Up .............................. 85 Discharge Planning Outcomes ..................... 91 Survey Comments .................................... 96 Case Management Survey ............................. 97 Perceived Client and Family Concerns .................... 98 Perceived Client and Family Concerns and Planned Follow-Up ........................................ 102 SUMMARY OF FINDINGS, DISCUSSION, CONCLUSIONS, AND RESEARCH IMPLICATIONS ...................... 109 Summary of Findings and Discussion .................... 109 Discharge Planning Survey ...................... 110 Planned Follow-Up ............................. 113 Case Management Survey ....................... 114 Perceived Client and Family Concerns ............. 115 Conclusions ........................................ 1 18 Discharge Planning Survey ...................... 118 Perceived Client and Family Concerns ............. 120 Perceived Client and Family Concerns and Planned Follow-Up .................................. 122 Research Implications ................................ 124 viii Implications for Service Providers ................. 125 Public Policy Implications ........................ 127 Future Research ............................... 128 Ecological Implications .......................... 135 APPENDICES A. Survey Cover Letters, Reminder Letters, and Reminder Post Cards ........................................ 138 B. Case Management Post Card .......................... 144 C. Survey Results Post Card ............................. 145 D. Discharge Planning Survey ............................ 146 E. Case Management Survey ............................ 157 F. Glossary .......................................... 166 LIST OF REFERENCES ......................................... 168 BIBLIOGRAPHY ............................................... 180 10. 11. 12. 13. LIST OF TABLES Acute and Chronic Illness Rates for the Elderly, 1983 ............... 6 Regional Distribution of Michigan's Acute Care Hospitals That Responded to the Survey ............................... 64 Responding Hospitals Categorized by Bed Size .................. 65 Number of Annual Inpatient Medical-Surgical Discharges in Responding Hospitals ...................................... 66 Medicare Percentage of Total Annual Inpatient Discharges in Responding Hospitals .................................... 67 Number of Discharge Planners in Responding Hospitals ........... 70} Number Of FTE Discharge Planning Employees in Responding Hospitals ................................................ 70 Educational Preparation of Discharge Planners in Responding Hospitals ................................................ 72 Amount of Orientation Received by New Discharge Planning Employees in Responding Hospitals ........................... 73 Amount of Orientation Received by Continuing Employees in Responding Hospitals ...................................... 74 Type of Job Preparation in Responding Hospitals: New or Continuing Employees ...................................... 75 Percentage of Time Spent on Discharge Planning in Responding Hospitals ................................................ 76 How Clients Were Identified for Discharge Planning Services in Responding Hospitals .................................... 79 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. Criteria Used to Identify Discharge Planning Clients in Responding Hospitals ...................................... 80 Primary Indicator of Need for Discharge Planning in Responding Hospitals ...................................... 80 Average Percentage of Discharge Planners’ Time Spent on Coordination of Community Services ........................... 82 Average Percentage of Discharge Planners’ Time Spent on Administration/Papewvork ................................... 83 Average Percentage of Discharge Planners’ Time Spent on Assessment of Clients and Families ........................... 83 Average Percentage of Discharge Planners’ Time Spent on Client and Family Counseling ................................ 84 Responding Hospitals With Planned Follow-Up ................... 86 Regional Distribution of Responding Hospitals With Planned Follow-Up ................................................ 86 Bed Size of Responding Hospitals With Planned Follow-Up ......... 87 Number of Discharges for Responding Hospitals With Planned Follow-Up ................................................ 87 Percentage of Total Annual Medicare Discharges for Responding Hospitals With Planned Follow-Up ............................. 88 Planned Follow-Up Contact Person in Responding Hospitals ........ 88 Criteria Used by Responding Hospitals for Identification Of Clients for Planned Follow-Up After Discharge ................... 89 Primary Purpose of Planned Follow-Up After Discharge in Responding Hospitals ...................................... 90 Average Length of Planned Follow-Up Time After Discharge in Responding Hospitals .................................... 91 Discharge Planner Average Daily Client Caseload in Responding Hospitals ...................................... 92 xi 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. Percentage of Discharge Planners’ Average Daily Caseload Who Were Medicare Clients ................................. 93 Number of Closed Cases Per Discharge Planner Per Month ........ 93 Reasons Why Case Management Was Not Implemented ........... 95 Estimated Percentage of Responding Hospitals’ Annual Caseload That Needed Case Management ...................... 95 Means and Rankings of Discharge Planners’ Perceptions of Clients’ and Families’ Concerns ............................... 99 Distribution of Responding Hospitals’ Ranking of Perceived Client Concerns .......................................... 101 Distribution of Responding Hospitals’ Ranking of Perceived Family Concerns ......................................... 102 Analysis of Variance: Perceived Client Concerns by Planned Follow-Up ............................................... 104 Analysis of Variance: Perceived Family Concerns by Planned Follow-Up ............................................... 105 Pearson Correlation Coefficients: Perceived Client Concerns and Planned Follow-Up .................................... 106 Pearson Correlation Coefficients: Perceived Family Concerns and Planned Follow-Up .................................... 107 xii LIST OF FIGURES Discharge Planning Eco-Model: Chronic Illness in Elderly Cardiovascular Clients ...................................... 19 Regional Distribution of Michigan’s Acute Care Hospitals That Responded to the Survey ............................... 63 Percentage of Time Spent on Discharge Planning Activities ......... 81 xiii CHAPTER I INTRODUCTION Emblemfitatemem Recent federal legislation changed hOSpitaI reimbursement for all Medicare Clients (see Appendix F for Glossary: Prospective Payment System). This placed new pressure on discharge planning for clients, families, and health providers. Concerns about health care quality and access quickly followed. In response, some hospitals expanded and refined their discharge planning and utilization review efforts to better control client length Of stay and facilitate discharges (Zander, 1988). Others developed and implemented more innovative programs for monitoring clients and for controlling costs and length of stay (Ethridge & Lamb, 1989; Loveridge, Cummings, & O’Malley, 1988; Martin, 1989). Yet, either on a national or state level, limited research has been done to describe or evaluate hospital-based models of discharge planning and case management. One barrier to the study of hospital discharge planning and case management programs is the use of multiple labels for the programs offered and a lack of common definition of the terms (Blumenfield, 1986). Not infrequently, personnel in hospitals who provide utilization review activities are titled case 1 2 managers, or discharge planners are titled case managers when their job functions are those of traditional discharge planners. Other hospital staff who monitor resource allocation and utilization of services by clients, and thus provide managed care services, also are titled case managers. A compounding problem is the rapid change in hospital discharge programs and the lack of available information about hospital practices and any innovations that have been implemented. Another barrier to study is inherent in the process itself. Discharge planning is a dynamic process in which continued feedback from the client and family in the form of added information, clarified communication, or modified goals is needed to Sharpen the focus of the process. Yet client and family involvement in the decision-making process varies. Clients’ physical status and emotional availability; the families’ understanding of the illness and its implications; Client and family attitudes about hospitalization, medication, treatment, and planning; family and client expectations and goals; and the consistency between family goals and community resources are examples of factors affecting the amount and quality of participation in the process. Although this researcher did not examine the efficacy of different discharge planning and posthospital care programs, the discharge functions and activities, including planned follow-up after discharge, were described. The researcher examined the questions and concerns of high-risk, older cardiovascular clients with prolonged chronic illness and their families before 3 discharge, as perceived by hospital personnel primarily responsible for discharge planning. Burmese The researcher’s overall purpose in this study was to conduct a survey of Michigan’s acute care hospitals in order to identify and describe the discharge planning and case management services provided, and to document discharge planners’ perceptions of the concerns of Older cardiovascular clients and their families before discharge. Planned follow-up in relation to the perceived concerns of cardiovascular clients and their families was examined. Scope of the Problem | I I I. I II E I I Cl' I I E .I. Clients and their families often have many questions and concerns when they are told about an impending discharge from a hospital. Many families think that the client is not ready to go home and that the discharge is premature. However, Clients do not have the option to remain in the acute care setting until they are completely well. New government and insurance directives require discharge as early as possible. With earlier discharge, responsibility for care and rehabilitation quickly shifts from the hospital to the client and family, Often leaving the family and client confused, resentful, and overwhelmed. This faster pace 4 makes the process of discharge planning more difficult, especially when time is short and alternatives difficult to evaluate (Hartigan 8. Brown, 19853). Deseltals Hospitals have experienced significant changes in utilization and reimbursement patterns over the last 10 years (American Hospital Association [AHA], 1994b). The length of stay and rate of client admissions to the inpatient setting have declined during the 19803 and 19905 (Medicare 8 Medicaid, 1989). This has been due, in large part, to the passage by Congress of the prospective payment system (PPS)-Public Law 98-21, the Social Security Amendments of 1983—in the spring of 1983 and implementation of the program, which began in October 1983. The primary objective of the PPS was to slow the rate of growth of hospital costs while ensuring access of beneficiaries to quality health care (Guterrnan & Dobson, 1986). Under PPS, reimbursement to hospitals is based on the average length of stay for Clients who fall within specific diagnosis-related groups (DRGs). Hospitals receive a fixed amount of money based on the relative costs of resources used to treat clients within each type of DRG (ASA, 1994a). Besides the introduction ofthe PPS for Medicare patients, other third-party payers either pay or negotiate preferred provider contracts with hospitals, based on DRGS (US. Department of Commerce, 1990). To survive in this more competitive environment, hospital administrators are continuously seeking programs and 5 methods that decrease the cost of providing client care while maintaining quality (Guterrnan 8 Dobson, 1986; Medicare 8 Medicaid, 1989). CardicxascmaLDlseaseandfldeflLEeLsens Since 1900, the patterns of illness among all age groups in the United States have Changed dramatically, with a decline in infectious diseases and an increase in chronic diseases such as heart disease (Markson, 1992). National statistics have indicated that, of those adults suffering from multiple chronic illnesses, more than half were suffering from cardiovascular disease (American Heart Association, 1994). (Another 20% had cancer and/or rheumatoid arthritis. The remaining 25% were Clients with long-term illnesses such as emphysema, diabetes, asthma, Parkinson’s disease, diverticulitis, multiple sclerosis, and cardiovascular accidents.) Causes of death also have changed. The five leading causes of death nationally are heart disease, cancer, stroke, pneumonia, influenza, bronchitis, and accidents and suicide (American Heart Association, 1994). In 1900, heart disease ranked fourth as a cause of death (Office of the State Registrar, 1993). In Michigan, the leading cause of death also was heart disease. In 1991, 296 persons per 100,000 population died of heart disease in Michigan, compared to 283.3 persons per 100,000 population in the United States (American Heart Association, 1994). In a 1993 survey from the Michigan Department of Public Health, it was found that almost 82% of Michigan adults had one or more of the risk factors for cardiovascular disease. Although patterns of disease and life expectancy have changed markedly since the turn Of the century, the reduction in morbidity (i.e., the number Of cases of disease within a specified population) has been much lower (Dawson, Hendershot, 8 Fulton, 1987). As more people live into old age, chronic diseases have increased as causes of illness and disability, so that there are now more elderly persons with conditions for which no cure exists. The majority of those 65 or Older today have at least one Chronic condition; many have multiple health problems. Arthritis, hypertension, hearing impairments, and heart disease are the most frequent Chronic diseases among Older Americans today (American Heart Association, 1994). (See Table 1.) The American Heart Association indicated that one of three persons at age 65 has had some form of heart disease or stroke. 6 Table 1: Acute and chronic illness rates for the elderly, 1983. Chronic Condition Rate/1,000 Population Total 65 years 8 Older Heart conditions 82.8 303.0 Hypertension 121.3 387.9 Arthritis 8 rheumatism 131.3 471.6 Of interest to discharge planners and case managers are national utilization data by major diagnostic category (MDC), which Show that diseases of the circulatory system (including cardiovascular disease) account for the 7 highest number of discharges and patient days. In 1991, only the MDC "circulatory system" accounted for more than one million patient days (Office of the State Registrar, 1993). In addition, state inpatient hospital utilization data by age categories reveal that persons over 65 years accounted for almost 30% of Michigan’s hospital discharges in 1991, and nearly 41% of the inpatient days. The average length of stay for persons older than 65 years of age (8.6 days) exceeded the average length Of stay for persons younger than 65 (5.2 days) by 3.4 days (Michigan Hospital Association [MHA], 1993). Although there are no universal criteria for determining which Clients benefit from discharge planning, most screening guidelines include persons over age 70 who are suffering from multiple chronic diseases (Rorden 8 Taft, 1990; Zarle, 1987). El I I E .I C D' I El E I. The hospital discharge planner has to focus on the reality that hospitalization is a transitional and time-limited part of a process. Because discharge planning for older clients usually is initiated early in the hospital stay, options for posthospital care have to be explored while clients’ medical prognosis remains uncertain. Posthospital discharge planning for these Clients is difficult because it requires a cooperative effort by Clients, family, and professionals to ”visualize how to extend the needed health care (which may be unfamiliar to the client and family) into the home or institutional setting (which may be unfamiliar 8 to the professional)" (Johnson 8 Fethke, 1985, p. 230). Elderly cardiovascular clients often require care that is different from that of their younger counterparts. Their needs and those of their families often are different, which leads to different questions and concerns before discharge. In interacting with the elderly client and his or her family, the discharge planner concentrates on client and family needs, goals, objectives, and the matching Of services to fulfill those needs. However, "any client who packs his suitcase for the hospital includes more than a toothbrush, a pair of pajamas and a bathrobe—he adds his worries, concerns, anxieties, and fears which involve him and his family as well as his community" (Hartigan 8 Brown, 19850, p. 27). It is not unusual that, before discharge, concerns arise that center on medical as well as nonmedical needs. Therefore, while identifying needs and problems of a practical sort, the discharge planner has to listen for concems—either stated or implied—Of clients and families, and has to view these concerns from both a person and problem perspective. QIienflEamily Eerspegtive With elderly cardiovascular clients being discharged "sicker and quicker,” both they and their families often find themselves facing impending discharge with considerable fears and worries(Tiemey, CIOSS, Hunter, 8 Macmillan, 1993). The client who has a stroke, myocardial infarction (heart attack), and/or cardiac surgery now finds himself or herself weakened physically and perhaps taking new medications. He or she might be confronted with the need for an altered 9 diet and/or exercise regimen. If surgery has occurred, there might be follow-up, i.e., dressings. Understandably, client "worries" include: Is ”it" going to happen again? Can I return to past activity? Can I have sex? What do I do if I experience pain or Shortness of breath? Can I go out of town? Families, too, are scared and worried: Is it safe for the client to be left alone? Can they travel? Can the Client drive, walk the dog, clean the driveway, rake leaves? Should they nag when the client does things the doctor said he or she should not do? How will they know whether the client needs to go back to the hospital? Most clients and families have not had the time to think of home care plans. Many have no idea of the options available to them, or, if they do, they have not had the time to explore those options. Financial concerns loom ever- present. Both clients and families are fearful about the client’s weakness and overall medical condition. They are concerned about the required level of home care and their ability to provide it. Most elderly clients need family caregiving for at least several weeks, which often is difficult for previously independent persons. The effect of life style changes is overwhelming at times for both Clients and families. Although both clients and families are aware that they will need to make sacrifices (particularly dual-working families with children), most have no way of realistically anticipating what awaits them alter discharge from the hospital. [I I El . All hospitalized clients expect to receive at least a basic level of discharge planning service to ensure appropriate discharge (Joint Commission on 1O Accreditation of Healthcare Organizations [JCAHO], 1994). The Society for Hospital Social Work Directors (SHSWD, 1984) of the American Hospital Association described discharge planning as any activity that facilitates the transition Of the client from one environment to another. The discharge planning principles include (a) a determination of the patient’s posthospital care preferences, nursing and medical needs, and capacity for self-care; (b) assessment of the patient’s living conditions; (C) identification of health or social care resources needed to ensure high-quality posthospital care; and (d) counseling of the patient or family to prepare them for posthospital care (SHSWD, 1984). Clients identified as having complicated discharges because Of functional limitations or lack of assIStance in the home generally are referred for discharge planning services. These services are provided by a discharge planner, usually either a social worker or a nurse. Traditionally, when the client is discharged from the hospital, the intervention of the discharge planner ends. No follow-up contact is made with the client, the family, or the physician following the Client’s hospitalization to determine whether the services provided were appropriate or adequate (Simmons 8 White, 1988). In some hospitals, discharge planning services do not end at discharge. There is some contact with the client, the family, or the Client’s physician following discharge to determine whether the postdischarge services are appropriate, adequate, and effective. The discharge planner intervenes when 1 1 problems are identified, makes appropriate adjustments in the care plan, and then monitors the client’s progress for a relatively short period of time. BDSDIIaEBasedCaseManagemem Case management, the coordination of Client health care and/or community services, begins either at the time of client admission or shortly thereafter, and continues following the client’s hospital discharge for an unspecified length of time (Ethridge 8 Lamb, 1989; Simmons 8 White, 1988). The length of time over which case management evaluation and intervention occur is determined by the client’s physical and psychosocial status and the success of the care plan that is in effect. If the client no longer needs case manager follow-up, the case manager puts the Client on an inactive list, with occasional contact or no contact unless the client’s condition changes, requiring further intervention by the case manager (Ethridge 8 Lamb, 1989). Not every client receiving discharge planning services requires posthospital care in the form of case management. The most effective use of case management services is to target clients who are at high risk for institutionalization or hospital readmission and those with complex in-home needs (Simmons 8 White, 1988). The primary difference between discharge planning which has some follow-up contact and case management is the length of time over which the Client is followed. Case management is longer term and for an indefinite length of time, depending on Client need (Ethridge 8 Lamb, 1989). 12 Although there are several similarities between discharge planning and case management services, the purpose of case management is broader (White, 1988). The goal of discharge planning is to assure continuity of client care while ensuring the shortest possible stay. ltS objective is to move the client out of the acute care setting swiftly and safely, while assuring continuing care in the posthospital care setting that best extends the care plan received in the inpatient setting (Simmons 8 White, 1988; White, 1988). The overall goal of case management is to provide a service delivery approach to client monitoring in the community setting. Case management services are used to (a) ensure cost-effective care, (b) provide alternatives to institutionalization, (c) provide access to care, (d) coordinate services, and (e) improve the client’s functional capacity (Simmons 8 White, 1988). Significance Before the introduction of the prospective payment system for reimbursement, hospitals had no compelling incentive for monitoring clients after discharge (Beck, 1987; Brody 8 Persily, 1984; Rosen, 1985). Neither monetary, social, nor legal conditions presented motives for client follow-up. Since the introduction of PPS, this situation has changed, and hospitals now have incentives for providing intensive discharge planning services and follow-up after discharge. Hospital costs have continued to increase, escalating the total costs of providing health care in acute care settings and making it difficult for hospitals to 13 be competitive in the market (AHA, 1994b; Office of National Cost Estimates, 1990). Discharge planning programs that incorporate some degree Offollow-up and case management have the potential to decrease the clients’ length of stay and thus total costs of care. These programs provide a mechanism for monitoring selected clients following discharge to ensure effectiveness of the discharge plan and to make revisions in the discharge plan as necessary. Ultimately, discharge planning and case management might be a factor in preventing costly and unnecessary rehospitalization or institutionalization of elderly chronically ill clients. Before empirical studies can be conducted to compare the efficacy of innovative case management and discharge planning programs, it is first necessary to define and describe the programs that are being used by discharge staff in acute care hospitals. This information currently is not available for hospitals in Michigan. This study is significant in that it is intended to identify and describe the discharge planning and case management services provided by acute care hospitals in Michigan, including planned follow-up after discharge. Such a description of discharge services provides information for hospitals that are considering the implementation of similar programs. Previously, one could only speculate whether there were any hospitals that provided case management services or that had discharge planning staff who provided planned follow-up. 14 This researcher also documented discharge planners’ perceptions of the concerns of elderly cardiovascular clients and their families. She examined whether these concerns were related to planned follow-up after discharge. Cardiovascular clients were chosen because, of those persons over 65 years of age who had medical diagnoses, more than half suffer from cardiovascular disease (Hartigan 8 Brown, 1985c). Often, after a period of hospitalization, these clients still require further intermittent care. but not hospitalization. The quality of discharge planning for the elderly cardiovascular client literally means the difference between life and death or the difference between a life of independence and well-being and one of dependence and disability (Kruse, 1985). Failure to adequately meet postdischarge needs for elderly Clients might affect the health of a frail spouse, create tremendous family sacrifice and strain, or create social service needs that affect an entire community. The economic and social costs of such failure are staggering. One way of anticipating unmet needs after discharge might be to look at how well client and family concerns were addressed before discharge. From the discharge planner’s viewpoint, those concerns or questions expressed by the Client and/or the family might point out which topics had not been satisfactorily covered and needed more attention. In addition, attention to these concerns might increase client/family satisfaction levels, improve public relations, and lessen or diffuse issues that might have escalated into litigation. 15 Examination of Client and family concerns before discharge, within the context of planned hospital follow-up procedures, also might encourage a critique of the current discharge planning system to (a) elicit Client and family input into discharge planning activities; (b) examine the family role in elder care; and (C) explore interventions to enhance the family role, with improved outcomes for both the client and family. Tubman (1986) reported that just as the chronically ill person’s health Changes over time, the nature and extent of family support also changes. This becomes more evident as family involvement changes from concern about the person’s health to taking direct action in giving care. Thus, in considering the concerns of the elderly cardiovascular client and his or her family before discharge, it is important to consider not only the trajectory Of the elderly person’s illness but also the qualitative and quantitative changes in family support over the duration of the caregiving experience (Johnson 8 Catalano, 1983). Discharge planners need to be alert to incongruencies between client and family concerns and to get the perspectives of both before discharge. Consulting with appropriate family members might aid in detecting problems in care arrangements and/or family relationships and in working toward more realistic caregiving goals and role responsibilities. Clearly, each family situation is unique in some way, and the discharge planner needs to take this uniqueness into account before recommending care alternatives. 16 Theoretical Framework Human ecological theory provided the conceptual framework for this research. Golant (1984) noted that views ofthe "purposively behaving individual” must be combined with an understanding of contextual boundaries and constraints. The ecological approach can be used to explore the interdependencies and interrelatedness between humans and their environments, and allows one to examine humans within their context (Bronfenbrenner, 1979; Bubolz 8 Sontag, 1993; Constantine, 1986; Kantor 8 Lehr, 1975; Wright 8 Herrin, 1988). In the model developed by Bubolz and Sontag, the environment was defined as the sum total of the physical, biological, social, economic, political, aesthetic, and structural surroundings of human beings. It was conceived as "a set of nested structures, each inside the next” (Bronfenbrenner, 1979, p. 3). These subordinate environments—natural physical- biological, human built, and sociocultural—interact with each other and with an individual or group, all within the larger environment. There is a relationship of ”reciprocal influence” among components of the environmental system. An interaction between any single component or person "influences or acts on any other part and is influenced or acted on in turn” (Bubolz, Eicher, 8 Sontag, 1979, p. 30). A strength of human ecological theory is its holistic approach to influences on human behavior and potential throughout the life course. Aging is a complex and varied experience, influenced by the social context in which it takes place an In} 17 (Kahana, 1982). Consistent with a transactional view of aging, older persons are not simply pawns bullied by environmental factors; rather, negotiations take place between individuals and their environments. The choices and accommodations arising from such negotiations are reflected in the complexity and diversity of contextual effects (Ward, La Gory, 8 Sherman, 1988). Although Older individuals play an active role in "creating" their own experiences, this does not necessarily occur under conditions of their own choosing. Chronic illness, for example, might reduce behavioral options, limiting flexibility in thetransactions between a person and the environment. In this study, an ecological approach provided a framework to help focus on specific aspects of the complex processes of discharge planning while not losing Sight of the dynamics of the whole. Discharge planning takes place in contexts that in turn shape the discharge planning process. Contextual interpretation of discharge planning requires exploration of all interdependent environments that impinge on the client-family in some fashion. These include relationships between Clients and family members; between the client-family unit and health care professionals; between the Client-family unit and the hospital, third-party payers, regulatory and accreditation agencies, and other aspects of the sociocultural environment; and between the client-family unit and society as a whole. Each of the environments interacts with the other components and with the client to set limits and to mold the possibilities for Client meaning and experience at discharge. Ci: inf. IErI 18 The variability of aging means that there is no one typical older patient. Thus, the discharge planner has to attend carefully to the need for person- environment congruence while making an idiographic recommendation specific to the Client’s unique situation (Constantine, 1986). Adaptive decision making during the discharge planning process highlights the complexity of environment- behavior relations for the older client, where not just the context but the psychological, spiritual, and physical state Of the person is critical. Older clients have diverse environmental needs, preferences, concerns, and responses. As they adapt to contextual conditions, the adaptations that they make are themselves complex (Kahana, 1982; Ward et al., 1988). Human ecological theory has great utility for discharge planning because it acknowledges the ever-Changing interplay among family Characteristics, human attributes, and environmental factors and how these affect environmental outcomes and developmental outcomes (Westney, 1993). The dynamic interactions occurring during discharge planning which require a holistic model are illustrated in Figure 1. The human ecological perspective allows a point of convergence among the environments asthey bear on discharge planning as an interactive process. AS shown in Figure 1, the resourcing, allocating, and integrating of discharge planning’s component tasks throughout the health care continuum are influenced by significant and interacting environmental variables. A creative tension inevitably exists among the goals and wishes of the Client, the concerns 19 GOVERNMENT REGULATIONS 943:5 7:3;r- ' " 72... . ';‘:-;i . v: ‘.'. ~ ' ‘ .. .. .\ ..-/ J .1 * ESPLANNEB _. ;, :2; '.--:;:§. z. , . 3. '/,'.\'f/, ..; \fijy. . "t '1?" . :-;-. .5239; , ’3 . t , g I . . , , ‘; ”‘2’ 7;_ ' .'.‘ .. , ‘I _ “..' 'r. I .' z ., .‘u .u,-.\.a,-..-.. -‘-‘.'-“-'- 1., (7. Ir“.;: ‘.;.:.~ :.~.»} in“. - ..- .;-.:.' 4.3. {:7 l ' I.;.;_ 7.1. " . s, :3. '.;.'. -.:.j. --:‘.',’, 57:" :3". gag/'2'. '_ -- :3. ~;;. 1.3.: .:»:‘ ~ . . ;;::..-:;;;;.;-: :‘-: :35: 3:32; ,><\z>::;zt’:i;§: .,-.u.,t:g._; "2'3"":‘3‘1'9-“3‘15 .; . ‘44, ,I . >575R1‘5FE'5' ‘37.; HEALTH CARE / PROFESSIONALS t .7 COMMUNITY ACUTE STABILITY EPISODE CONTINUITY OF CARE I > TRANSITION > Figure 1: Discharge planning eco-model: Chronic illness in elderly cardio- vascular clients. 20 of the client’s family, the policies of the individual health care facility, and the health care policies Of the various levels of government providing reimbursement for services. Yet a discharge plan has to be negotiated to meet these Often- divergent needs. The model graphically conveys what “ideal" discharge planning is and is not. It is not (a) limited to concern about the physical transfer of the client, (b) focused only on the physical-care needs of the client, (c) an activity that is done to or for the client, or (d) the responsibility of the discharge specialist alone. Discharge planning is a process that begins with early assessment of anticipated client-care needs. It does include concern for client total well-being. It does involve the discharge planner and client and family caregivers in a dynamic, interactive communication process. It does place a priority on collaboration and coordination among all health care professionals involved. It has as its goal a mutually agreed upon decision about the most economical and appropriate options for continuing care. By definition, discharge planning is an episodic process that facilitates the transition of health care—not the client--from the hospital to another environment. During the acute phase, medical attention dominates. During the transition phase, although the needs for acute care are still present, new needs emerge centering on the next setting of care. The physical transfer of the client to a new care setting marks the final part of the care transition. After a period Of 21 adjustment, the client enters the continuing-care phase, and discharge plans begin to be implemented. Conceptual Definitions W. Hospital-based service (versus community-based) that focuses on ensuring appropriate and continuous care for selected clients after discharge. It is an on-going, on-Site, individualized "bridging" process that coordinates the services of multiple care providers—both health and social services. It involves assessing clients’ needs, identifying any gaps or errors in discharge plans, revising plans of care as necessary, and locating, coordinating, and/or monitoring a defined group of services or resources (Blumenfield, 1986; O’Hare 8 Terry, 1988; Simmons 8 White, 1988; Well, Karls, 8 Associates, 1985; Zane,1987) Client. Used in its broadest sense to encompass not only the Sick individual (patient) but the person who takes a more active role in participating in her/his own discharge planning process (Hartigan 8 Brown, 19853). Community. "Has both geographical and interactional components. It is people in interaction bound together by common needs and resources" (Rorden 8 Taft, 1990, p. 148). W. Awide range of resources, including but not limited to visiting nurse care, homemaker provider assistance, home-delivered meals, medical equipment, and transportation services. ma uni the inle ma Inllur Bro IC (192 a‘r'aI care 22 Concern. "A matter that relates to or affects one; something of interest or importance; anxiety; worry" (WW 1969. p. 275). W. For this study, continuing care planning and discharge planning were synonymous (see below). W. The coordinated delivery of health services on a continuum. Continuity of care refers to future goals, whereas continuing care refers more to a present process (American Association for Continuity Of Care, 1993; Hartigan 8 Brown, 1985a; McKeehan, 1981; O’Hare 8 Terry, 1988; Volland, 1989). mm. A hospital-based designated professional who manages and coordinates the discharge planning process. Dischargeplannjng. A collaborative process involving the Client-family unit and health care professionals to facilitate the transition of health care from the hospital to another environment. It is exit planning and episodic. The intention is to ensure that the high-risk client in need of posthospital care has a planned program for safe, high-quality, continuing or follow-up care (Hartigan 8 Brown, 1985a, 1985C; O’Hare 8 Terry, 1988; Simmons 8 White, 1988; Tuzman 8 Cohen, 1992; Volland, 1989; Zarle, 1987). The American Hospital Association (1984) definition is "an interdisciplinary hospital-wide process that should be available to aid patients and their families in developing a post-hospital plan of care” (p. 3). 23 W. The unit of individual(s) primarily responsible for the transition of care for high-risk clients leaving the hospital. family. A “group of two or more persons related by marriage, blood, adoption, friendship or guardianship” (McNamara, 1985, p. 30). fiigh;dslg_cljents. Persons with complex medical and related needs, but limited or nonexistent material resources and social support systems. These also are persons whose needs may change frequently overtime and may require repeated adjustments ofhospital-prepared discharge plans. Two basic concerns are continued medical supervision and personal care (Crittenden, 1983; Zarle, 1987) W. Business whose specialty is providing care to persons at home. Hamehealmcare. Services provided to individuals and families in their place of residence forthe purpose of promoting, maintaining, or restoring health or minimizing the effects of illness and disability. Examples are skilled nursing, social services, speech therapy, occupational therapy, physical therapy, community services, home health aides, or homemaker services (Crittenden, 1983) Managedcare. Overall strategy is to direct consumers to the best care for the best cost. It is a combination of medical care, utilization review, and insurance-plan design in which risk is transferred from payer to provider. It is an approach to health care and maintaining health that seeks to assign the payer 24 an increasingly significant role in the decision making and management of health care (Anders, 1994; Hurley, 1993; Meyer, 1993). Multidisciplinamcare. A team approach involving the as—needed expertise of various hospital professionals. Examples are dietitian, Chaplain, physical therapist, occupational therapist, and client educator (O’Hare 8 Terry, 1988; Weil etaL,1985) Need. "Condition or Situation in which something is necessary; necessity; obligation; exigency; requisite” (Americanilefitageflicflonary, 1969, p. 878). Nursingcareplan. Initiated by the primary care nurse, it is a written plan that identifies client problems, prescribed actions, and expected outcomes. It is used to evaluate client needs and progress (Zarle, 1987). ELOALIQQLS. These persons, institutions, and agencies offering medical and social services. Examples include hospitals, physicians, mental health therapists, physical therapists, visiting nurses, social workers, and dentists (Hartigan 8 Brown, 1985a, 1985b; Meyer, 1993). W. A process of examining the efficiency of the hospital, the appropriateness of admissions, services ordered and provided, length of stay, and discharge practices on both a concurrent and a retrospective basis (Berkman, 1989; Meyer, 1993). Limitations and Assumptions This was an exploratory, descriptive study of discharge planning and hospital-based case management programs in Michigan. It only served to 25 identify and describe discharge planning and case management programs and discharge planners’ perceptions of cardiovascular Client and family concerns. Therefore, conclusions drawn from this study Should be made with caution. The literature on discharge planning is extensive; however, standardized definitions of discharge planning and case management do not exist (Hartigan 8 Brown, 1985a; James, 1987; Rehr, 1986). As a result, the researcher developed definitions at the onset of this study to reflect concepts widely discussed in the literature by professionals involved in discharge planning and case management. The response rate, although 37%, was lower than hoped. Hospitals in the 25- to 99-bed category were the most frequently represented group. The majority of hospitals with planned follow-up also had between 25 and 99 beds. The sample size (N = 57) and the size of the responding hospitals should be considered when drawing any conclusions based on this study’s findings. Another limitation was the setting. All acute care hospitals in Michigan were surveyed in this study; the results might not be applicable to other states. Findings from this study also were limited because they were filtered through the perceptions of discharge planners and case managers. Therefore, the results could not be assumed to represent the entire picture of concerns of elderly Clients and their families. In addition, concerns were limited to those Of elderly cardiovascular clients and their families, and were not generalizable to all elderly clients or all families of elderly clients. ergl Ila. CGIIC It... .Ic'JE the I In: 26 The researcher made the following assumptions throughout the study: 1. Because of prospective reimbursement coupled with an increased emphasis by payers on managed care, hospitals had an incentive to decrease lengths of stay and readmission rates by developing innovative discharge planning and case management programs. 2. As providers of health care, hospitals sought to balance financial concerns with quality-of-care concerns. 3. Clients and families had concerns before discharge that might not have been identified and/or addressed by the discharge planner in developing the care plan. 4. Families were not always involved in the discharge planning process. Research Objectives The researcher’s overall purpose in this study was to identify and describe the discharge planning and case management services provided by acute care hospitals in Michigan, and to document discharge planners’ perceptions of the concerns of older cardiovascular clients and their families before discharge. Toward this aim. the researcher had two specific Objectives: 1. To conduct a survey of Michigan acute care hospitals to describe the range and types of discharge planning and case management services offered to clients both during and after discharge. EISEI AI'AOI I559. BIS-3 3983 Its: Ctr: 308‘ 27 2. TO document discharge planners’ perceptions of the concerns of elderly cardiovascular Clients and their families before discharge. The relationship of those perceived concerns to planned follow-up after discharge also was examined. Besearchfluestiens The research questions for this project were: 1. What are the structural, process, and outcome characteristics Of discharge planning and case management programs in Michigan’s acute care hospitals? 2. What are discharge planners’ perceptions of the concerns Of elderly cardiovascular Clients and their families before discharge? 3. What is the relationship of discharge planners’ perceptions of concerns of elderly cardiovascular clients and their families to planned posthospital follow-up? Although there is minimal research available about actual or perceived client and family concerns before discharge, one expects that the importance of certain concerns, as perceived by discharge planners, would be related to planned follow-up. Perhaps clients and families who know they will receive no follow-up contact will be more focused on immediate medical issues-for example, catheter care or pain-management techniques—whereas those clients and families who expect ongoing contact for a period of time might be more concerned about psychosocial issues. «Ito‘s: 959v“- I"? “Gill . Ira; Ill-j 28 Before this study was undertaken, it was not known what types of discharge planning services were offered by hospitals in Michigan. No information was available on which hospitals contacted clients after discharge from the hospital, and, if Clients were contacted, which ones were contacted, what was the method of contact, and how long planned follow-up lasted. Many hospitals call their discharge programs case management, but it was not known what similarities or differences existed between programs, or whether case management was just discharge planning with a new name. Nor had researchers examined the concerns Of clients and families before discharge. This exploratory study was thus an initial step in gathering information about discharge planners’ perceptions of concerns of elderly cardiovascular Clients and their families and discharge planning and case management programs in Michigan. CHAPTER II REVIEW OF THE LITERATURE As background for this study, selective literature related to caregiving, client and family concerns, discharge planning, case management. and quality Of Client outcomes was reviewed. Family Caregiving In the past decade, considerable research was conducted on the important role of the family in the care of the chronically ill elderly, dispelling the myth of family abandonment (Brody, 1985; Hagestad, 1986; Johnson 8 Troll, 1992; Moss, Moss, 8 Mole, 1985; Shanas, 1979). In one study, 96% of all older persons had at least one family member who provided support to them while they were in the hospital. Following hospitalization, almost 90% of clients aged 65 or older returned home (Cicirelli, 1990). In most cases, support from family members was provided during the convalescence period. When an older person needed long-term care, the family played a major role in that care for as long as possible. Typically, the Older person was cared for in his or her own home or in the home of an adult child (Cicirelli, 1988, 1991). The societal benefits of what is often full-time caregiving by family members are now widely recognized and 29 30 appreciated (Albert, 1990; Brody, 1985; Crossman, London, 8 Barry, 1981; Lee, 1988; Zarit, Orr, 8 Zarit, 1985). Numerous studies have suggested associations between social support networks and preventive health behaviors, reduced risk of illness, compliance with medical regimens, a more successful recovery process, and lower mortality rates (Cicirelli, 1990; Coulton, Dunkle, Goode, 8 Maclntosh, 1982; Fischer 8 Eustis, 1988; Franks 8 Stephens, 1992; Langlie, 1977). More recent research has corroborated that families provide both tangible and intangible support to the chronically ill older person (Brody, Litvin, Albert 8 Hoffman, 1994; Whitbeck, Hoyt, & Huck, 1994). Another body of literature has documented the need to consider the nature of chronic illness and its effects on the family overtime (Johnson 8 Morse, 1991 ). Researchers have found that, with regard to the client’s family, acute and terminal illness are far more acceptable than chronic Illness. In Chronic illness, the length Of time that family members will be involved is uncertain, and their adjustments are varied. In addition, family members often have difficulty accepting a person whose ambulatory status has changed; thus, a person in a wheelchair is Often less acceptable than a bedridden person. Interestingly, studies have shown that chronic illness in the young can be tolerated and accepted by families more readily than it can in the aged (Markson, 1992). Although the family support network can be large in Size, family members differ in the kind and amount of support provided during illness. In general, the 31 hierarchy of care is a spouse as the major support of support, followed by adult female children if the spouse is unable or unavailable to give support (Brody et al., 1994; Johnson 8 Troll, 1992; Longlno, 1990). Other kin (especially those living at a distance) tend to come in for shorter periods of time in an acute situation (Cicirelli, 1991; Shanas, 1979). Research on the frail elderly has depicted a different support network. Although this client might need even more assistance after hospital discharge (Kane, Ouslander, 8 Abrass, 1984; Noelker 8 Wallace, 1985), this age group is the least likely to have assistance available to them. Frail elderly clients are more apt to live alone; many of the persons previously relied on for physical and emotional support might have died, or because of their own disability are unable to provide what care is needed (Kane et al., 1984; Noelker 8 Wallace, 1985). Care responsibilities then evolve onto the second and the third generations. Contrary to popular belief, children (and nieces and nephews) are usually concerned and involved in the care of elderly clients when possible (Bengston, 1979; Brody, 1985; Whitbeck et al., 1994). However, there are situations that make adequate care arrangements difficult: distance, job responsibilities, and demands of their own families, for example (Cicirelli, 1988; Stoller 8 Pugliesi, 1989) The demands of caregiving and their effect on the caregiver and the family as a whole have been well documented (Archbold, 1982; Beach, 1993; Brody, 1985; Cantor, 1983; MCCubbin 8 Patterson, 1982; Montgomery 8 Borgatta, 32 1989; Stone, Cafferata, 8 Sangl, 1987; Zarit, Todd, 8 Zarit, 1986). While families accept the responsibility to care for their members, the number of older persons needing at least minimal help is greater than ever before. However, because of smaller family size, the burden of care is potentially spread among fewer people. In addition, recent studies adopting a family systems perspective have related how stress and strain radiate to other family members—for example, as multiple family members become involved in sharing the tasks of caring for an impaired elder (Beach, 1993; Creasey, Myers, Epperson, 8 Taylor, 1990; Brody, Kleban, Johnson, Hoffman, 8 Schoonover, 1987). Client and Family Concerns The shift of responsibility for health care management of an individual to the health care team during hospitalization and back to the individual at discharge is an important yet potentially difficult transfer, especially for elderly clients (Johnson 8 Fethke, 1985). Even more relevant than medical issues isthe stress of hospitalization to an individual who already has to cope with many changes and losses. Rossman (1977) stated: We physicians tend to accept hospitalization without question as a convenient, beneficial and necessary milieu for acute care. . . . In making these casual judgments, we tend to underestimate the trauma . . . produced when a frail elderly person in equilibrium with a known environment is transferred to a strange one. (p. 107) The social service and medical literature discussed client and family education as one means of easing the transition from hospital to home (Murray, Garraway, Akhtar, 8 Prescott, 1982). The same body of literature Indicated that, by 33 anticipating potential problems before they arise, client and family outcomes might be improved. In spite of Rossen and Coulton’s (1985) call for empirical research to examine the discharge planning community’s assumptions about what methods of discharge planning are most effective, little research of this type has been done. Even less research has sought to measure concerns of elderly clients and their families before discharge and whether response to concerns might be related to improved outcomes. Some researchers have investigated concerns but in another population; others have focused on discharge planning for the elderly, but not on client and family concerns before discharge. To date, most discharge planning has been evaluated in terms of efficiency, planning process, and readmission (Johnson 8 Fethke, 1985; Schrager, Halman, Myers, Nichols, 8 Rosenblum, 1978; Arenth 8 Mamon, 1985; Waters, 1987). Few studies have focused on the quality of the product of discharge planning, which is the posthospital care plan itself. Few studies have examined how suitable plans were to clients’ needs at discharge, whether client and family concerns were addressed before discharge, and how well plans worked over time. In interviews following discharge, Morrow-Howell, Proctor, and Mui (1991) found that expression of concerns by clients, families, and hospital staff about the adequacy of discharge plans often represented underlying disagreements among those involved in planning. Further, they concluded that, in situations where families and clients were not involved in 34 developing discharge plans, the clients’ needs might not be well met following discharge. Their findings underscored the importance of facilitating client and family involvement. Lack of information about care plan adequacy was due partly to the fact that most discharge planning departments do not follow patients after discharge to assess the stability and adequacy of care plans (Quinn, 1992). Instead, they use hospital data to determine how quickly clients leave and how long they stay out. However, Rhoads, Dean, Cason, and Blalock (1992) evaluated discharge planning outcomes by actually visiting clients in their homes within two weeks after discharge. They found caregivers who were frightened at the responsibilities of caregiving, and often had health problems of their own. They found Clients who had trouble purchasing medications prescribed at discharge and discovered that the discharge planning team often had neglected to discuss the costs of medications and the clients’ ability to purchase them. They also found that 50% of the family caregivers and clients could not perform the home care skills demonstrated to them in the hospital. Although a substantial body of literature Clarified the critical role the Client’s social support network plays in care and recovery (Brody, 1985), there has been minimal research about family concerns, either before or after discharge. Most research has focused on discharge planners’ concerns. Rehr (1986), in an editorial, enumerated discharge planners’ concerns as having to do with premature discharge, level of illness, and how well clients and families were 35 prepared in terms of developing realistic expectations for immediate and long- terrn functioning. Other concerns have to do with the availability of formal and informal support systems to help the clients after discharge. In Otkay, Steinwachs, Mamon, Bone, and Fahey’s (1992) evaluative study of discharge planning for the elderly, findings were presented as concerns of discharge planners. These included greater availability of resources (32%), better cooperation of family (28%), and better cooperation of the client (20%). Discharge planners’ concerns about the discharge plan itself centered on lack of flexibility (48%), and that the family support system would prove inadequate (45%). In 32% of the cases, it was thought that clients would not be able to manage a regimen because of cognitive or physical limitations. Interestingly, discharge planners’ concerns focused more on families and clients than on problems in existing formal services. Proctor, Morrow-Howell, Albaz, and Weir (1992) studied Client and family satisfaction with discharge plans. They interviewed clients and families within 24 hours before discharge. Their findings are important because of the potential to reveal how two important consumer groups, clients and families, evaluated discharge plans in light of their predischarge concerns. Overall, clients were more focused on their physical condition, reflecting their concerns about their ability to function and about who would provide their care. In contrast, family member evaluations were influenced by the amount of time the discharge planner invested, by the number of options considered, and by the involvement 36 of the client in decision making. Their findings suggested that clients required involvement in decisions and reassurance about their care after discharge; families required time, professional attention, and a thorough planning process. Two other studies, although they did not address the concerns of the elderly population before discharge, have generic utility for the discussion. Gehl and Lantzy (1990) studied parents’ concerns after infants’ discharge from the neonatal intensive care unit (NICU). They asked what parents would have found helpful regarding care after discharge, and whether discharge instructions evolved from the health care providers’ concerns or from parents’ identified needs and concerns. Their findings supported that parents had specific unmet needs in relation to expected infant care activities after discharge. Two areas of concern identified by the sample were infant feeding and participation in the discharge planning process. The only study that documented the questions and concerns of clients and families was Glennon and Smith’s (1990) work in the rehabilitation setting. Residents assigned to rehabilitation units kept track of issues raised during family conferences for the purpose of providing complete, accurate, and improved discharge planning. Consistent with their client mix, they found that one-third ofthe questions/concems were directly related to the primary rehabilitation diagnosis. Whereas the findings from these studies might not be generalizable to elderly clients and their families, the fact that the researchers acknowledged and studied client and family concerns before discharge is important. 37 Discharge Planning Hospital discharge planning was defined by the American Hospital Association (AHA, 1984) as an "interdisciplinary hospital-wide process that should be available to aid patients and families in developing a feasible post hospital plan of care" (p. 3). Such planning began in 1906 at Massachusetts General Hospital, when Dr. Richard Cabot established the first department of social work (Blumenfield 8 Rosenberg, 1988). This department comprised social workers, nurses, and others whose function was to "augment the physicians’ treatment of patients by studying, reporting and alleviating to the extent possible the patient’s social problems which interfere with the plan for medical care" (Cannon, 1913, pp. 14-15). The discharge planning literature suggested that changes in hospital reimbursement, which occurred during the 19803, motivated hospitals to alter their discharge planning services. The implementation of DRGS had a direct effect on decreasing client lengths of stay and thus decreasing the time available for discharge planning (Blumenfield 8 Rosenberg, 1988; Bull, 1988; Coulton, 1988; Dinerman, Seaton, 8 Schlesinger, 1987). Blumenfield (1986) further recommended that discharge planning be extended from the hospital into the community following client discharge. Services would include psychosocial interventions, telephone follow-up, and case management to be targeted to chronically ill clients with records of recidivism (Blumenfield, 1986; Blumenfield 8 Rosenberg, 1988). Justification for postdischarge follow-up services was 38 based on the belief that a cost-benefit would be achieved in improved public relations and in prevention of unnecessary rehospitalizations (Blumenfield 8 Rosenberg, 1988). Case Management Although relatively new to the acute hospital setting, case management is not a new concept. Case management services have been in place and studied in public health, mental health, and |ong-term-care settings and reported in the literature for many years (Steinberg 8 Carter, 1983; Weil, Karls, 8 Associates, 1985). Community service coordination, which was a forerunner of case management, began: around the turn Of the century in public health programs. Service coordination eventually evolved into case management, a term that first appeared in the social welfare literature during the early 19705 (Grau, 1984). The concept of ”continuum of care" came into use following World War II to describe the long-term services required for discharged psychiatric patients (Grau, 1984). Case management has many definitions. One is: ”Case management is a set of logical steps and a process of interaction within a service network which assures that a client receives needed services in a supportive, effective and cost- effective manner" (Weil et al., 1985, p. 2). In the Omnibus Reconciliation Act (OBRA, 1981) (PL 7970-35), case management was defined as "a system under which responsibility for locating, coordinating, and monitoring a group of services 39 rests with a defined person or group" (p. 373). Both definitions are broad enough to be used with a variety of case management models. Many terms are used to describe case management. These include care management, case coordination, continuing care coordination, and service coordination. Some hospitals, health maintenance organizations (H MOS), and the insurance industry use the term "case management“ to describe what might be described more accurately as "utilization management," orthe monitoring and control of service utilization within a system or episode of care, with the primary goal Of cost control (Secord, 1987). Yet, there are some providers in these groups that have case management programs that go beyond utilization control, and monitor the client following discharge from the hospital. Case Management and Elderly Persons Historically, it has been identified that many older people have special and often multiple health needs that are population specific, and that these needs are not adequately served in age-generic programs. Thus, elderly persons who are home-bound or have complex problems that place them at risk for institutionalization often are targeted for case management services (Secord, 1987). However, not all older people who need multiple services require a case manager. Assessments of functional status and social support are perhaps better determinants of which clients require case management, rather than chronological age. Clients who have an adequate functional status and can coordinate and access services forthemselves. orthose who have social support 40 in the form Offamily members, orformal or informal caregivers who provide these functions for them, do not need a case manager (Steinberg 8 Carter, 1983). Rather, these individuals require adequate information about their options and the services available. In the acute care setting, this information could be provided by the nurse providing direct care, the client’s physician, a discharge planner, or a case manager. Purpose of Case Management It is generally agreed that case management comprises seven basic dimensions. These include: 1. Identification of the target population. 2. Screening/intake and eligibility determination. 3. Assessment. 4. Care planning. 5. Service arrangement. 6. Monitoring and follow-up. 7. Reassessment (Weil et al., 1985, p. 29). Case management in the acute care setting has two purposes: one client- centered and one system-centered. The purpose of Client-centered case management is to assist the client through the complex, fragmented, and often confusing health care delivery system. In system-centered case management, it is recognized that health care resources are finite and have to be managed and allocated. Case management serves as a rationing and priority-setting function 41 that targets those individuals in the population who would most benefit from specific services (Kane, 1985). Stetler (1988) indicated that the goals of case management include the proper allocation of resources for client care, provision of continuity in care, and facilitation of Client discharge within an appropriate length Of stay. Hospital-Based Follow-Up Studies of models of discharge planning with some follow-up and of hospital—based case management were described in the literature. Two models that provide discharge services for elderly persons are discussed in the following paragraphs. W This was an experimental study of 132 clients, 75 years of age or older, admitted to Victoria General Hospital in Nova Scotia, Canada, on an emergency basis between April and September 1985. Sixty-six clients (50%) were in the control group and were attended by their physicians following hospital discharge. Sixty-six Clients were randomly assigned to the experimental group and received follow-up by the geriatric service after hospital discharge. The intervention consisted of client interviews by trained nurse assessors, and a mental-status questionnaire if the client was able to participate. All clients were classified based on the Geriatric Status Scale. Clients in the experimental group were seen and treated by the Consultant Team (GCT), which included a specialist in 42 geriatric medicine, a nurse coordinator, an occupational therapist, a physical therapist, a social worker, a dietician, and a representative from pastoral care. Clients were seen daily Monday through Friday during hospitalization, either by the nurse coordinator or the physician, with team rounds once a week. The focus of the program was to address functional problems and to provide postdischarge follow-up. At the time of discharge, the assessor reinterviewed each Client, collecting the same data as at the initial assessment. Postdischarge follow-up continued by either telephone or written contact to a total of 56 Clients in each group. In addition to the usual postdischarge care provided by the family physician, Clients in the experimental group were also followed and received interventions provided by the GCT. Thirty-two received written or telephone follow-up to either the Client or the involved caregivers, who were contacted by telephone at 3, 6, and 12 months following discharge. Ten people were seen in the Geriatric Outpatient Clinic. Nine received a home visit by the physician and either the nurse coordinator or the assigned occupational therapist. Three were admitted to the Geriatric Day Hospital, and two to the Geriatric Inpatient Unit. Results of the study suggested a statistically significant longer survival rate among clients in the experimental group, up to approximately 180 days following discharge. One year following hospital discharge, there was no statistically significant difference between the two groups. GCT clients showed an improved survival rate during the first year, improved functional capabilities, 43 and a trend toward decreased reliance on hospital and nursing homes (Hogan 8. Fox, 1990). BJALJDDDSDDCaseManagemem D II'E'I A 1988 demonstration project, funded by the Robert Wood Johnson Foundation, established 24 hospital-based case management programs in the United States. The project methodology involved two rounds of surveys and case studies of 16 project sites. The surveys used the hospital as the unit of analysis, and gathered qualitative and quantitative information. Surveyquestions requested information on the project goals, total project activities and services, organizational location, staffing patterns, the features and tasks of case management, hospital financial information, and the numbers and characteristics Of case management participants (MacAdam et al., 1989). The 16 case studies focused on analyzing the strengths and weaknesses of four selected approaches or models to hospital provision of long-term-care services. Interviews were conducted with key hospital and project staff members (MacAdam et al., 1989). Several problems were encountered in the evaluation ofthe project. Total cost data for case management and most of the other services were not available in most of the sites due to the hospitals using a variety of cost centers in charging project services. Measurement error occurred in determining the functional impairments of clients because the projects collected assessment data on clients at different times. 44 Only two sites, Massachusetts General Hospital and Parkland Memorial Hospital (Texas), implemented research protocols. Their research designs limited the number of clients admitted for services. All other projects served as many elderly persons as possible. The hospital-based case management projects encountered several difficulties, including the problem of using vaguely defined targeting criteria, being poorly linked to medical care, and an inability to document changes in outcomes as a result of the provision of case management (MacAdam et al., 1989). Conclusions drawn from the demonstration project showed that "case management could take a variety of forms, ranging from postacute medical management services to planning continuity-based care for potential long-term care users" (MacAdam et al., 1989, p. 737). Misunderstandings about the differences between discharge planning and case management services were documented, which had led to frustrations among staff. Recommendations for future research included concentration on documentation of the cost and quality Of outcomes of various forms of case management, including transition management, and closer linkages to medical care for elders with chronic impairments (MacAdam et al., 1989). Quality of Care Any discussion of case management and discharge planning needs to consider the quality of care provided, particularly within the cost-containment environment of prospective reimbursement (Jennings 8 Meleis, 1988). Defining 45 and providing quality of care to clients in acute care settings long has been a challenge for the health care industry. In 1912, the Third Clinical Congress of Surgeons of North America, which later evolved into the Joint Commission on Accreditation of Hospitals (JCAH), resolved that hospitals with high ideals should have proper recognition, and those hospitals with inferior standards should be stimulated to improve the quality of their work (Davis, 1960). Afrequent occurrence in health care is the lack of definition ofquality, and separate evaluations of the costs and quality of care (Larson 8 Peters, 1986). Quality usually is presented as a perception or feeling, and hospital personnel Often are placed in the position of defending quality without being able to quantify or define it (Jennings 8 Meleis, 1988). Donabedian (1969) reported that it is difficult to define quality of health care, but that it can be promoted by evaluating process and outcome variables. He stated that quality of care cannot be defined without taking into account issues of cost (Donabedian, 1980), and that quality of care depends on the appropriate objectives of care and then on ways to attain them (Donabedian, 1987). Donabedian attempted to solve the problem of evaluating the quality of care provided to hospitalized clients by developing a model that divided quality assurance into three components: structure, process, and outcome. Structural components related to human, organizational, environmental, and physical resources and standards of practice. Process components focused on what 46 professionals did in the delivery of health care. Outcome aspects related to the consequences of client care (Donabedian, 1980, 1987). Donabedian (1980) stated that there was a causal linkage between process and outcome, and that either could be used to assess quality. Olsen and Lyon (1989) indicated that several factors comprised the concept of quality of care. These included standards Of care, ethics and values, safety, prevention, costs, client satisfaction, critical thinking or reasoning, utilization patterns, and monitoring. All of these factors fell within the scope of hospitals’ quality assurance programs. The amount Of influence placed on any portion of the quality assurance program was determined by hospital administration, nursing and medical staff, and consumer input (Olsen 8 Lyon, 1989). As they worktoward defining quality ofcare, some researchers and health care organizations believe quality can be ensured by reducing the use of unnecessary health care services, whereas others believe it can be ensured by setting performance standards for providers. Other experts listen to consumers’ demands for quality health care and explore ways to measure clients’ health status and incorporate this information into quality standards (Graham, 1987). Often researchers have focused on measuring quality of care, independent ofthe hospital’s acceptable standards in the organization-wide quality assurance program (Graham, 1987). 47 D II [C IEII I Cl' I The cost and quality outcomes for clients older than 65 often are not measured by acute care hospital staff. It has been said that the quality of care provided to elderly persons needs to be improved (Fink, Siu, Brook, Park, 8 Solomon, 1987). Since the introduction of prospective hospital reimbursement based on DRGS, studies of the quality of elderly client outcomes have begun to emerge In the literature. The Rand Corporation sponsored a federally funded study that was published in 1990. The study sample included 14,012 Medicare clients with five physical conditions: (a) congestive heart failure, (b) acute myocardial infarction, (c) pneumonia, (d) cerebrovascular accident, and (e) hip fracture. Clients within these five disease groups were compared for the level of impairment at discharge before and after the implementation of the Prospective Payment System (PPS) (Kahn et al., 1990). Client outcomes, pre and post PPS, were compared after adjusting for sickness at admission (Kahn et al., 1990). As Donabedian (1987) had suggested in the literature, process-outcome links were established, and better process of care was shown to be associated with better outcomes. The results of the study showed that instability at the time of client discharge Significantly predicted postdischarge death. One example provided was that at 90 days postdischarge, 16% Of clients discharged unstable were dead, compared with a 10% death rate for clients discharged stable (p < .01). 48 The conclusion drawn was that after PPS there was an increase in client instability, primarily among clients discharged home. Before PPS, 15% of clients discharged home were unstable, and after PPS, 18% were unstable (p < .01), a 22% relative change. The researchers concluded that Clients were being discharged from the hospital setting ”quicker and sicker" underthe PPS system, and recommended that efforts to monitor the effect Of PPS on health should be implemented (Kosecoff et al., 1990). The results of the Rand study provided further justification for the implementation of expanded forms ofdischarge planning programs and/or case management that would Specifically monitor clients who were unstable following discharge. Appropriate referral of such Clients to medical care and other services might prevent unnecessary deaths. It is not enough simply to monitor the cost ofcare provided. Measurement and evaluation of client outcomes are important in order to draw conclusions of the cost-effectiveness Of client care. II I'IC .. I I'll' QLIILQSQIIEIS In the 19703, the Joint Commission recognized the need to evaluate the quality and appropriateness of care provided. Initially, the JCAH established medical audits as a methodology for measuring the quality of care delivered to clients. Medical care was reviewed according to specific criteria. The standards, however, did not suggest any specific methodology by which care should be evaluated (Fromberg, 1986). 49 In 1975, hospitals were required by the JCAH to demonstrate that the quality of Client care consistently was Optimal by continually evaluating care through reliable and valid measures. Health professionals were required to establish or adapt explicit, measurable criteria. Methodologies for retrospective, outcome-oriented audits emerged (JCAH Supplement, 1975). In 1979, the JCAH introduced new standards, which required that studies be performed to review and evaluate the quality of care. The focus was problem- oriented, centering on problem identification, resolution, and documentation of the process (Decker, 1985). In 1984, the Quality Assurance (QA) standard for hospitals again was revised. An organization-wide program for QA replaced the previous problem- focused approach. Standards that specified systematic monitoring and evaluation of important aspects of client care and service were required. The new standards stressed actions taken by staff in the institution, and evaluation of the effectiveness in improving client care and resolving identified problems (Lehmann, 1987). In 1990, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, formerly JCAH) changed to a new evaluation methodology that focused on clinical and organizational performance. The emphasis on outcome versus process indicators depended on the specific clinical specialty being addressed (JCAHO, 1994). 50 The Joint Commission’s stated purpose for this Change was to develop clinical indicators in approximately 25 specialty areas. Performance information would build a database of comparable data that would be accessible to hospitals. These clinical indicators were to serve as a guide for health professionals conducting problem analysis and peer review. They were meant to flag possible problems in performance and to address the problems through appropriate action. Follow-up monitoring would be required to ensure that the action had solved the problem. Problem resolution was a key part Of the JCAHO standards for quality assurance. The Joint Commission also acknowledged that severity of illness or case complexity adjusters needed to be incorporated into the measurement process. Clearly, not all clients experienced problems because the care delivered was faulty. The outcomes for severely Ill Clients were less likely to be Optimal than for other clients. As a result, the JCAHO planned to develop an effective formula adjustment to reduce the number offalse results concerning Clinical performance (Rowland 8 Rowland, 1989). The discharge planning, case management, and quality-of-care literature frequently referred to the difficulty that hospitals had in keeping costs undertheir reimbursement levels. Added to this problem was the increased competition for both inpatient volume and outpatient revenue (AHA, 1994b) and the need to maintain quality client outcomes (Guterrnan 8 Dobson, 1986). It is within this 51 environment, where economic issues are juxtaposed with quality-of—care issues, that today’s elderly clients receive acute care. CHAPTER III METHODOLOGY The methodology for this study is described in the following sections. Included are the research design, sample, instrumentation, pilot study, process Of data collection, and data analysis. Research Design The aim of this exploratory descriptive study was to survey all acute care hospitals in Michigan that had medical-surgical services as their primary client service. The study documented discharge planners’ perceptions of the concerns of elderly cardiovascular clients and their families before discharge and examined the relationship of these concerns to planned posthospital follow-up. Inflamnb A survey was mailed to Directors of Discharge Planning and Continuing Care in 156 acute care hospitals in Michigan “that provided services to medical/surgical clients. Eligibility criteria for hospitals included JCAHO accreditation, AHA acute care hospital accreditation, AHA classification as having medical-surgical services, and AHA classification as short-term stay (the 52 53 average length of stay for all clients was fewer than 30 days). Accreditation information came from the AHA (1994a) guide. The list of acute care hospitals was obtained from the Michigan Hospital Association’s membership directory (MHA, 1994). All acute care hospitals in Michigan belonged to the MHA, with the exception of the University of Michigan Hospitals in Ann Arbor, which were added to the survey. The sample included all hospitals in the sample frame. Only acute care hospitals were included; thus, psychiatric, state hospitals, military and veterans hospitals, rehabilitation and chemical dependency facilities, nonacute, and pediatric specialty hospitals were omitted. Data-Collection Methods BackgmundJanrmaflDD General background information on each hospital (geographical location and bed size) was collected bythe researcher from the AHA (1994a) guide orthe MHA (1994) membership guide. To examine the geographical distribution of responding hospitals, they were grouped into eight regions. These regions were defined by the MHA according to county. The AHA guide, which sorted hospitals by state, by city, and by county, was used by the researcher to identify the county in which each hospital was located. IheJnstLument The survey instrument was developed by the researcher. It consisted of two separate surveys. The first survey, on discharge planning, was sent to all 54 hospitals in the sample. The original survey mailing included a post card, coded for identification, which asked whether a hospital offered case management services. For those hospitals that indicated “yes,” a supplemental case management survey was sent to the Director of Case Management. The discharge planning questions asked the number of discharge planning employees, the number of full-time equivalents (FTES), and the educational preparation Of each discharge planning employee. Data on the amount ofjob orientation discharge planning employees received were collected. Percentage breakdown of time spent by the discharge planning staff doing discharge planning activities, utilization review, quality assurance, or other activities was gathered. Hospitals were asked how clients were selected to receive discharge planning services. Another question requested a percentage breakdown of the time spent on predischarge activities. A question followed on the concerns of cardiovascular clients and their families before discharge. This question asked the discharge planner to rank (from extremely important to not important) his or her perceptions of the concerns of elderly cardiovascular clients and their families. A list of 14 concems/issues was provided by the researcher. This list was generated from the literature and from conversations in the Grand Rapids area with discharge planners, continuing care managers, a cardiologist, and the cardiac-rehabilitation manager at Blodgett Memorial Medical Center. 55 Discharge planners were asked whether limited follow-up contact with clients after discharge was part of their departmental procedures. If they responded positively, they were asked to complete a group of questions about their follow-up procedures. Last, participants were asked whethertheir hospitals offered case management, and whether a case management program had been considered. Directors Of Case Management at those hospitals for which a post card was returned received the case management survey. This survey provided data on when case management services were initiated by the hospital, and whether case management was part of the discharge planning department or a separate function with different staff. Case managers were asked whether their services were provided instead of discharge planning or in addition to discharge planning. Many of the same questions that were asked in the discharge planning survey (number of staff, amount Of staff orientation, educational preparation, and activities) were asked of case managers. Data were collected concerning how case management was funded in the hospital, the criteria used to determine the need for case management services, and how clients were referred for case management services. Respondents also were asked why case management was implemented in their facility, what information was collected on each client, and how case management benefited the elderly cardiovascular client and his or her family. 56 InstrumentDeILeIDDment During the instrument-development phase, the medical, business, nursing, family, health, and social work literature was reviewed to extract information about the historical and current status of the health care environment, family and health issues, and, more specifically, the emergence of hospital discharge planning and case management. ln-person and telephone conversations were held with hospital discharge planners and community-based case managers in Grand Rapids, Michigan, to gather preliminary information for inclusion in the survey, as well as to familiarize the researcher with related terminology. Also, telephone contact was made with a researcher from the Michigan Hospital Association who had been involved in a 1989 study of delays in hospital discharges. EIIQI The Michigan State University Committee on Research Involving Human Subjects (UCRIHS) reviewed and approved this research before its initiation. Before the distribution of the mail survey to hospitals in Michigan, the survey was sent to 10 Directors of Discharge Planning in midwestern hospitals as a pilot. This pilot sought to identify any problems with the survey design and to test any problems with coding the survey results. Ten hospitals were selected at random from the American Hospital Association (AHA, 1994a) list of member hospitals in the states of Illinois, Wisconsin, and Ohio. Problems identified in the pilot, 57 mainly terminology related, were corrected before distribution of the survey to Michigan hospitals. 9 'IIC til I. II Although individual hospital identities were known to the researcher through a coding system for responses, respondents’ identities were kept confidential. NO questions asked the names of respondents, addresses, or telephone numbers. No hospital identities were referenced in any survey findings. The survey responses were kept in a file cabinet in the researcher’s home with all dissertation-related records. A post card was included with the survey, to be mailed separately if the respondent wanted to receive aggregate survey results. The independent return of the post card precluded any ability to match the hospital’s address on the post card with the survey. Validity The comments and review of the survey by the pilot hospital discharge planners, along with the various interviews conducted during the instrument- development phase, served as validation of the content of the survey. This minimized threats to the content validity of the survey. W19 In an attempt to maximize the response rate, 10 days following the initial mailing of the survey all hospitals that had not returned the survey were mailed a reminder post card. This card emphasized the importance of the study and the 58 need for their survey response. Ten days following that post card mailing, the remaining nonrespondents were mailed a letter again emphasizing the importance of their participation, along with another survey. DataAnalxsls The final study sample is discussed and the survey responses are described in this section. (With only two Michigan hospitals identified with established case management programs, analysis of case management findings is very brief.) There were three phases of analysis: (a) general description of discharge planning programs, (b) documentation of discharge planners’ perceptions of the concerns of elderly cardiovascular clients and their families before discharge, and (c) determination ofthe relationship of discharge planners’ perceptions of client concerns and family concerns to planned follow-up. The study’s three research questions provided the framework for analysis. Research Question 1. What are the structural, process, and outcome characteristics of discharge planning and case management programs in Michigan’s acute care hospitals? Descriptive statistics were used to summarize and present the results of the survey as they related to the structural, process. and outcome characteristics of discharge planning. Structural criteria included hospital size, geographical location, percentage of Medicare clients, annual discharges, staff educational preparation, and job orientation. Process criteria included how Clients were selected for follow-up services, the method Of contact, how long the contact 59 usually lasted. and staff activities. Outcome criteria included monitoring of readmissions, average caseloads, estimated need for case management, and the perceived benefits of case management. Examples of figures and/or tables presented in Chapter IV are: 1. 2. 8. Regional distribution of responding hospitals. Educational preparation of discharge planners. Type of job training for new or continuing employees. Percentage of responding hospitals providing follow-up services. Percentage of follow-up by method of contact. Average length Of time of follow-up. How clients were selected for follow-up. Primary purpose of follow-up contact. Research Question 2. What are discharge planners’ perceptions of the concerns of elderly cardiovascular clients and their families before discharge? Discharge planners’ perceptions of (a) the concerns of cardiovascular clients and (b) the concerns of their families or supportive persons before discharge were measured on a Likert scale of importance, ranging from ”extremely important" to ”not important” (see Appendix D, Question 22). Fourteen concerns or issues were listed, followed by an ”other" category. Means were computed for discharge planners’ perceptions of the importance of each 60 concern and family concern, and then ranked in descending order. Also, client means and family means were compared. Research Question 3. What is the relationship of discharge planners’ perceptions of concerns of elderly cardiovascular clients and their families to planned posthospital follow-up? lnferential statistics were used to examine the relationship between client and family concerns and planned follow-up. Discharge planners’ perceptions of both client and family concerns were measured using a Likert scale of importance. Analyses of variance (ANOVA) were performed to determine whether there was a statistically significant relationship (at an alpha level of .05) between each concern and planned follow-up. Pearson correlation coefficients (I) were computed to determine the nature and strength of the relationships. CHAPTER IV RESULTS In this chapter the study is discussed in terms of structural, process, and outcome criteria. Structural criteria referto the ”what" of discharge planning-—that is, clearly definable and measurable phenomena relating to human, organiza- tional, environmental, and physical resources and standards of practice (Donabedian, 1987). Process criteria focus on what discharge planning professionals do; their conduct and interaction with clients; and the activities, either direct or indirect, they perform in the delivery of health care. A discussion Of planned follow-up services is in a separate section. Process measures do not measure the clients’ progress or outcome. Outcome criteria focus on the consequences of client care—the consequences of discharge planning on the recipients. The responses obtained from the survey are described within the framework of the study’s three research questions. Individual participants were assured that their identities and their hospitals’ names would be kept confidential. Therefore, the survey findings are phrased generically in terms of ”hospitals responded. . . .” The survey was coded and data entered using the SPSS for 61 62 Windows statistical computer software program licensed to Michigan State University. Research Question 1. What are the structural, process, and outcome characteristics of discharge planning and case manage- ment programs in Michigan’s acute care hospitals? Discharge Planning Survey The geographic distribution Of Michigan’s 156 acute care hospitals is diverse. Sixty-three hospitals are located in nonmetropolitan areas and 93 are in metropolitan statistical areas (AHA, 1994). In 1991, the Southeast region of Michigan contained one-third Of the state’s community hospitals and nearly one- half of the state’s population (MHA, 1993). By comparison, 17% of Michigan’s hospitals, serving 33 counties and 7% of the state’s population in the North Central and Upper Peninsula regions of the state, often were the only hospital provider for a large geographic area (MHA, 1993). The hospitals participating in the study are distributed throughout Michigan, as represented in Figure 2. The percentage of response from within each region ranged from 13% to 89% (see Table 2). The highest response (89%) was from the South Central region. This was followed by the Upper Peninsula (47%) and the Southwest region (41%). The lowest response (13%) was from the Greater Flint region. All other regions had a survey response rate of between 24% and 36%. 63 Upper Peninsula (7) (47%) North Central (4) (2 %) East Central (5) (26%) West Central (7) (33%) Greater Flint (l) (13%) Southeast Southwest (18) (Job) (7) (41%) South Central (8) (89%) FiQure 2: Regional distribution of Michigan’s acute care hospitals that responded to the survey. 64 Table 2: Regional distribution of Michigan’s acute care hospitals that responded to the survey. Region NESSprEIZTIiItgals % of Total Region Southeast 18 ' 36 South Central 8 89 Southwest 7 41 West Central 7 33 Greater Flint 1 13 East Central 5 26 North Central 4 24 Upper Peninsula 7 47 Total 57 54% Mean Using US. Census criteria, 42% of the hospitals surveyed (N = 57) were located in nonmetropolitan areas, and 58% were in metropolitan areas. Sixty-five percent of the participating metropolitan hOSpitals were in the Detroit area. Twenty-two percent of the metropolitan hospitals were in the Grand Rapids- Muskegon-Holland area. tlDSDIIaLStLuctuLe Structural findings included in this section are hospital size, name of the department primarily responsible for discharge planning (DP), the department to which the discharge planning function reported, the title of the job primarily responsible for discharge planning, the annual number of inpatient medical- 65 surgical discharges, the percentage of Medicare clients, and the percentage of discharges that received the services of a designated discharge planner. The number of discharge planners, the number of FTEs, educational preparation of discharge planning staff, and new and continuing employee orientation are included under a separate section entitled staffing. II .I I S' The responding hospitals were categorized by their licensed bed size (AHA, 1994b). F ifty-one percent ofthe 57 hospitals in the sample had fewer than 100 beds, as compared to 57% for all of Michigan. The number of hospitals in each category is shown in Table 3. The sample as a percentage of total Michigan hospitals by bed size is given. Table 3: Responding hospitals categorized by bed Size (N = 57). Bed Size 6- 25- 50- 100- 200- 300- 400- 500 24 49 99 199 299 399 499 + No. of hospitals responding 1 13 15 10 7 4 3 4 % of total Michigan hospitals 13 41 44 35 35 27 43 35 The 25-49 bed, the 50-99 bed, and the 400-499 bed hospitals were the most frequently represented in the respondent group. The 500+ bed, the 100-199 66 bed, and the 200-299 bed hospitals also were well represented. Hospitals with fewer than 24 beds were the least represented. Hospitals’ bed size ranged from 18 to 855 beds, with a mean of 184 beds. The total number of acute care hospital beds represented by the sample was 10,500 beds. The bed size of acute care hospitals in Michigan ranged from 13 to 861. The mean bed size for all acute care hospitals in Michigan, the total population, was 180 beds. Total acute care beds in Michigan were 28,061. Discharges Twenty-one percent Of responding hospitals did not provide discharge data. Of the remaining hospitals, more than 50% discharged between 1,001 and 5,000 clients annually. The average number of discharges ranged from a low of 60 to a high of 77,151. The mean number of Client discharges was 7,464. The percentage breakdown of discharges is shown in Table 4. Table 4: Number of annual inpatient medical-surgical discharges in responding hospitals (N = 57). $282332; ”‘Eaé’s’p'lfiiifj" % Cumu'ative% Fewer than 1,000 8 17.8 17.8 1 ,001-5,000 24 53.3 71.1 5001-10000 2 4.4 75.6 10,001-15,000 4 8.9 84.4 15,001-20,000 4 8.9 93.3 20,001+ 3 6.7 100.0 , Missing 12 67 E I [I I I. D' I The percentage of annual inpatient Medicare discharges is shown in Table 5. Medicare clients represented between 20% and 95% of annual discharges. The mean percentage of Medicare discharges was 51.7%. Table 5: Medicare percentage of total annual inpatient discharges in responding hospitals (N = 57, n = 46). Numgfsrczfatgziicare Frequency % Cumulative % Fewer than 25 2 4-3 4'3 26-40 13 28.3 32.6 41-50 11 23.9 56.5 51-60 6 13.0 69-6 61-85 12 26.1 95.7 85+ 2 4.3 100.0 The percentage of total annual inpatient discharges that received the services of a designated discharge planner ranged from a minimum of 4% to a maximum of 100%. The mean percentage among the 49 hospitals (N = 57) that responded was 53.6%. 68 Denaflmentflame More than 50% of the hospitals indicated that their discharge planning departments were called either (a) Social Services (28.1%), (b) Social Work (24.6%), or (0) Medical Social Work (1.8%). Twenty-five percent indicated their department name was Discharge Planning, or either Discharge Planning and Social Services or Discharge Planning and Social Work. The third more frequent name category, after Social Work and Discharge Planning, was Continuing Care (10.5%). The remaining names included Patient and Family Services (3.5%), Client Services (1.8%), Social Services/Quality Assurance/Risk Management/ Utilization Review (1.8%), Community Home Care (1.8%), and Patient Referral Services (1.8%). Recedingfleeanment The most frequent reporting relationship for the discharge planning department was with hospital administration (24.6%). This was followed by nursing (21.1%), social work (21.1%), and utilization review (10.5%). The remaining 22% of respondents (N = 57) indicated quality assurance, quality review and utilization review, patient care services, medical records, quality review and continuing care, admitting, or rehabilitation. .IQILTIIIE Social worker (47.4%) was the most frequent job title. This was followed by discharge planner (24.6%) and Registered Nurse (RN) (7.0%). The 69 combination title, social worker and discharge planner, was indicated by 5.3% of the respondents. The remaining 16% Of respondents (N = 57) reported job titles of continuing care coordinator, home care coordinator, social work and home care coordinator, social services director, and social services/quality assurance/risk manager/utilization reviewer. Staffing Findings related to staffing are presented in the following categories: the number of discharge planners employed by each hospital in the sample, the number of FTES employed as discharge planners, their highest educational preparation, and the job orientation they received either as a new or continuing employee. NumbemLDjschargeElanners The number of discharge planners per hospital ranged from 1 to 23 (see Table 6). The mean number Of discharge planners was 4.81. Sixty-three percent ofthe hospitals had between 1 and 3 discharge planners. The surveyed hospitals reported a total of 274 discharge planners. The mean ratio of discharge planners to total hospital beds was 1 discharge planner for every 38 beds. The mean ratio of discharge planners to average monthly medical-surgical inpatient discharges was 1 discharge planner to every 102 discharges. II I [Ell-I' E . II The number of FTES for discharge planners in the participating hospitals ranged from .25 to .23. Sixty-five percent Of the hospitals responded that they 70 had between .25 and 3 FTES employed as discharge planners. Each FTE was employed full time, or 2,080 hours per year (see Table 7 for a detailed distribution of FTES). There was a total of 242 discharge planner FTES. This compared with 274 employees with discharge planning responsibilities. The mean ratio of discharge planners to total beds was 1 FTE for every 43 beds, and 1 FTE for every 116 medical-surgical discharges. Table 6: Number of discharge planners in responding hospitals (N = 57). NumbleDrIatfirgfsCIlarge Frequency % Cumulative % 1 24 42.1 42.1 2_3 12 21.1 63.2 4-5 4 7.0 70.2 64 3 5.3 75.4 8_9 5 8.8 84.2 10-14 3 5.3 89.5 15+ 5 10.5 100.0 Table 7: Number of FTE discharge planning employees in responding hospitals (N = 57). Number of FTES Frequency % Cumulative % 0-1 25 43.9 43.9 2-3 12 21.1 64.9 4-5 2 3.5 68.4 6-7 4 7.0 75.4 8-9 7 12.3 87.7 10-14 4 7.0 94.7 15+ 3 5.3 100.0 71 Whats Discharge planners were divided into two categories: nurses and non- nurses. Nurses were then categorized by highest educational degree received: 1. Licensed Vocational Nurse (LVN) 2. Diploma RN 3. Associate Degree RN (RN AD) 4. Bachelor of Science Degree RN (RN BSN) 5. Masters Degree in Nursing (MSN) or Master of Science (MS) 6. Other Education Non-nurse discharge planners Similarly were categorized: 1. Bachelors Degree in Social Work (BSW) 2. Master of Science in Social Work (MSW) 3. Social Work Technician (SW Tech) 4. Other Education The highest educational preparation of the hospitals’ combined 274 discharge planning staff is shown in Table 8. Of the total number, 66.4% (182) were non-nurses; 33.6% (92) were nurses. Fifty-eight percent of the hospitals surveyed had discharge planners with either a bachelors or masters degree in Social Work. Of the non-nurses, 67.6% had an MSW degree and 19.2% had a BSW degree. Of the nurses, 39.1% had an RN BSN degree and 33.7% had an RN degree. 72 Table 8: Educational preparation of discharge planners in responding hospitals (N = 57). Degree Number of Discharge Planners MSW 123 RN BSN 36 BSW 35 RN 31 Other 13 MS/MSN 11 RN AD BA SW Tech LVN Total 274 The responding hospitals employed discharge planners prepared with masters degrees in social work more than any other single educational category. Forty-five percent of all discharge planners held an MSW degree. Nurses prepared with RN BSWS (13.1%) and RNS (11.3%) were the next two largest educational groups. The ”other” education category comprised 4.7% (n = 13) of the total number of discharge planners. Degrees reported were Masters in Business Administration, high school diploma, Masters in Counseling, Associate degree in Respiratory Therapy, Masters in Administration and Health, RN Master of Arts, Ph.D., and a course in social service for long-term care. 73 Qdentaflsm The next section of the survey focused on the amount and type of orientation that discharge planning employees received. Three questions were asked concerning (a) the amount of orientation that experienced discharge planners received as new hospital employees, (b) the amount of orientation that hospital employees without previous discharge planning experience received when they transferred into the role of discharge planner, and (C) the type of training or preparation they received. Nemmployeeouematm. The amount of orientation for discharge planners who were new hospital employees ranged from not applicable (for hospitals that had not hired new employees either for a long time or from outside the hospital) to 22 days or more (see Table 9). Table 9: Amount of orientation received by new discharge planning employees in responding hospitals (N = 57, n = 56). Amount of Orientation Frequency % Cumulative % Not applicable 7 12.5 12.5 None 2 3.6 16.1 One day 4 7.1 23.2 2-7 days 21 37.5 60.7 8-14 days 9 16.1 76.8 15-21 days 11 19.6 96.4 22+ days 2 3.6 100.0 74 Quematieniemcntinuingemnlexees. Current hospital employees without previous discharge planning experience whotransferred into the role of discharge planner received. on the average, 2 to 7 days of orientation. More than 50% of the hospitals indicated they had not transferred current hospital employees into the role of discharge planner. This was reflected in the large number of ”Not applicable” responses (52.7%) (see Table 10). Table 10: Amount of orientation received by continuing employees in responding hospitals (N = 57, n = 55). Amount of Orientation Frequency % Cumulative % Not applicable 29 52.7 52.7 None 5 9.1 61.8 One day 1 1.8 63.6 2-7 days 11 20.0 83.6 8-14 days 5 9.1 92.7 15-21 days 3 5.5 98.2 22+ days 1 1.8 100.0 WEE Both on-the-job training (OJT) with an experienced discharge planner (24.5%) and the combination ofOJT, a procedure manual, and mentoring (24.5%) were the most frequent types of preparation. Seventeen percent of hospitals indicated the use of a procedure manual and OJT. Forty-four hospitals indicated that OJT was incorporated into training. Thirty-four used a training manual. 75 Twenty-eight mentioned a mentoring program. Videos were used less frequently and were mentioned by only eight respondents (see Table 11). Table 11: Type ofjob preparation in responding hospitals: new or continuing employees (N = 57, n = 53). Amount of Orientation Frequency % Cumulative % OJT 13 24.5 24.5 Mentor-OJT-manual 13 24.5 49.0 OJT-manual 9 17.0 66.0 Mentor-manual-video—OJT 5 9.4 75.4 Manual-mentor 3 5.7 81.1 OJT-mentor 3 5.7 86.6 Mentor 2 3.8 90.6 Manual-video 1 1.9 92.5 Manual-mentor 1 1 .9 94.4 Manual-mentor—video 1 1 .9 96.3 OJT-manual-video 1 1.9 98.2 None 1 1 .9 100.0 [1' I El . E Several questions addressed the process of discharge planning. These included how Clients were identified for discharge planning, the primary indicator of need for discharge planning services, and discharge planning functions and activities. Planned follow-up services after discharge are discussed in a separate section. 76 D' I El . E I. Hospitals were asked how much time their discharge planners spent on discharge planning, utilization review, peer review, counseling/psychological support, quality improvement, meetings and committee work, supervisory activities, and ”other" functions. These functions were identified during the survey-development phase and were verified by the pilot survey as primary functions of discharge planners (see Table 12). Table 12: Percentage of time Spent on discharge planning in responding hospitals (N = 57, [1 = 55). Percentage of Time Frequency % Cumulative % Dischargeelanning 1-10 1 1.8 1.8 11-20 1 1.8 3.6 21-30 4 7.3 10.9 31-40 6 10.9 21.8 41-50 6 10.9 32.7 51+ 37 67.3 100.0 W 0 46 83.6 83.6 1-10 8 14.5 98.2 11-20 1 1.8 100.0 ! III I. B . 0 32 58.2 58.2 1-10 13 23.6 81.8 11-20 1 1.8 83.6 21-30 5 9.1 92.7 41-50 4 7.3 100.0 77 Table 12: Continued. Percentage of Time Frequency % Cumulative % G I. IE I I . IS I 0 18 32.7 32.7 1-10 23 41.8 74.5 11-20 10 17.5 92.7 21-30 3 5.3 98.2 31-40 1 1.8 100.0 Q I! B . 0 19 34.5 34.5 1-10 33 60.0 90.5 11-20 2 3.5 98.2 31-40 1 1.8 100.0 II I. ID .II III I 0 9 16.4 16.4 1-10 39 68.4 87.3 11-20 6 10.5 98.2 21-30 1 1.8 100.0 E . E I. 0 41 74.5 74.5 1-10 12 21.8 96.4 11-20 2 3.6 100.0 The distribution of time spent on the discharge planning function ranged from 10% to 100%. The mean time spent was 64.1%. The majority (83.6%) of hospital discharge planners did not perform peer review activities. Of those who did, the mean amount of time spent was 5.6% (range = 1% to 20%). Most hospital discharge planners did not spend time on utilization review. Of those hospital discharge planners who had utilization review responsibilities, the mean time spent was 18% (range = 1% to 50%). Three hospitals reported that their 78 discharge planners Spent 50% of their time on utilization review. More than two- thirds Of the hospitals indicated that their discharge planners spent some time on counseling clients. The percentage of time spent ranged from 3% to 35%, with a mean time of 13%. Sixty percent of the reporting hospitals indicated that their discharge planning staff spent between 1% and 10% of their time on quality assurance functions. Thirty-five percent indicated that their discharge planners spent no time on quality improvement. The mean time Spent was 7%. Most hospitals (68%) indicated that their discharge planners spent between 1% and 10% of their time in meetings. The mean time spent was 9% (range = 2% to 25%). Three-fourths of the hospitals (74.5%) reported that their discharge planners did not function in a supervisory capacity. Of those who did have supervisory responsibility, the mean time spent was 7.4% (range = 3% to 20%). Seventeen percent ofthe hospitals indicated that discharge planners spent time on ”other" functions. These included long-term care and services, protective services, Special needs, appeals, and Lifeline manager. The percentage of time ranged from 2% to 70%, with a mean time of 26%. The three hospitals that reported more than 50% of time spent on ”other” functions specified screening and admitting residents to long-term care (70%). dealing with medical staff (60%). and social work (60%). Cl' I I I III I. Hospitals were asked how or by whom clients were screened to receive the services of a discharge planner. Thirty-seven percent (a = 21) indicated all 79 seven options offered. Thirty-three hospitals indicated a combination of these Options, which totaled 20 different responses. The frequency with which each option was mentioned is shown in Table 13. Table 13: How Clients were identified for discharge planning services in respond- ing hospitals (N = 57). Source Frequency Nurse 55 Physician 54 Social worker 45 _H_igh-risk screen 42 Community agency 27 Utilization review 26 Multidisciplinary team 29 I I III I. C .I . Seventy-seven percent of the hospitals responded that they used age, functional status, social support, and diagnosis to determine who was in need of the services of a discharge planner (see Table 14). Those hospitals that responded ”other" criteria indicated various combinations Of these four options, but not all four. Hospitals also were asked to indicate the primary indicator of need for discharge planning services. Functional status was reported by 55% of the hospitals (see Table 15). 80 Table 14: Criteria used to identify discharge planning clients in responding hospitals (N = 57, n = 56). Percentage of Time Frequency % Cumulative % Age 1 1 .8 1 .8 Functional status 1 1.8 3.6 All 44 77.2 82.1 Other 10 17.9 100.0 Table 15: Primary indicator of need for discharge planning in responding hospitals (N = 47, n = 43). Percentage of Time Frequency % Cumulative % _l_\ge 11 25.6 25.6 Functional status 24 55.8 81.4 Diagnosis 7 16.3 97.7 Other 1 2.3 100.0 [1' I El . I I. .I. Hospitals were asked, on average, the percentage of time designated discharge planners spent on the following activities: coordination of community services, administration and paperwork, assessment of Clients and families, counseling and advising Clients and families, and other. The total of all activities for each hospital equaled 100% (see Figure 3). 81 Coordination of Community Services Other (27.7%) (20.Q%) it i'fi-‘étgzz ‘ Administration/ Paperwork Counseling/ Advtsing (23.8%) Client & Family Assessment (28.5%) Figure 3: Percentage of time spent on discharge planning activities. 82 The average percentage of time spent, in descending order, was as follows: 1. 2. Assessment of Clients and Families (28.5%) Coordination of Community Services (27.7%) Advising Clients and Families (23.8%) Other Activities (20.4%) Administration/Papen/vork (18.1%) W. Ten percent ofthe hospitals reported that their discharge planners did not coordinate community services for clients. Of those hospitals indicating some time spent on coordination of community services, the time spent ranged from 5% to 60%, with a mean time of 28% (see Table 16). Table 16: Average percentage of discharge planners’ time spent on coordination of community services (N = 57, n = 55). Percentage of Time Frequency % Cumulative % 0 5 9.6 9.6 1-10 8 15.4 25.0 1 1-20 8 15.4 40.4 21-30 19 36.5 76.9 31-40 15.4 92.3 41-50 3.8 96.2 51 + 2 3.8 100.0 83 WOW Two hospitals reported no time spent on paperwork or administrative duties (see Table 17). Of the remaining hospitals, the mean time spent was 18% (range = 5% to 45%). Table 17: Average percentage of discharge planners’ time spent on administra- tion/papenNork (N = 57, n = 55). Percentage of Time Frequency % Cumulative % 0 2 3.8 3.8 1-10 20 38.5 42.3 1 1-20 17 32.7 75.0 21-30 10 19.2 94.2 31-40 2 3.8 98.1 41-50 1 1.9 100.0 WWW. Most discharge planners spent some time on assessment. The mean time spent was 28%, ranging from 10% to 70% (see Table 18). Table 18: Average percentage of discharge planners’ time spent on assessment of clients and families (N = 57, n = 55). Percentage of Time Frequency % Cumulative % 0 1 1.9 1.9 1-10 5 9.4 1 1.3 1 1-20 13 24.5 35.8 21-30 21 39.6 75.5 31 -40 10 18.9 94.3 51 + 3 5.7 100.0 84 WW. Seventy-seven percent of hospitals responded that their discharge planners spent between 11% and 30% of their time on counseling activities for clients and families. The mean time spent was 24% (range = 10% to 60%). Table 19 contains a summary of reported time spent on counseling activities. Table 19: Average percentage of discharge planners’ time spent on client and family counseling (N, = 57, n = 55). Percentage of Time Frequency % Cumulative % 0 2 3.8 3.8 1-10 4 7.5 11.3 1 1-20 26 49.1 60.4 21 -30 15 28.3 88.7 31-40 3 ' 5.7 94.3 41-50 2 3.8 98.1 51+ 1 1.9 100.0 QtneLagmities. Almost 80% of the hospitals indicated that their discharge planners spent no time on "other” activities. Ten percent of hospitals reported that their discharge planners spent from 1% to 10% of their time on ”other" activities. The remaining 10% of hospitals indicated that their discharge planners spent between 11% and 70% of their time on "other" activities. Activities that were specified included meetings, interdisciplinary collaboration, searching for extended-care—facility beds, utilization review, and social work. 85 I IT I S . Hospitals were asked whether they provided any services that traditionally had been offered in the community. Options included a home care program, sale or rental of durable medical equipment, a skilled or subacute care nursing facility, nursing home beds (contracted), and/or case management. Of the 48 hospitals responding, 29% indicated they offered no services. Eight percent of responding hospitals offered home care programs, 6% offered equipment sale or rental, and 13% offered a skilled or subacute care nursing facility. The remaining 44% of hospitals offered two or more of these services. The most frequent response (15%) was the combination of equipment rental and a nursing facility. Elann_e_d_EQ|J.0MtUQ In this section of the survey, hospitals were asked whether their discharge planning procedures included planned follow-up (e.g., phone calls, home visits). If they responded positively, they were asked to complete six questions about their planned follow-up. Forty hospitals indicated that neither their discharge planners nor other hospital personnel contacted clients following discharge from the acute care setting. Seventeen hospitals indicated that they planned to contact selected clients following discharge (see Table 20). The responses of those hospitals that indicated they had planned follow-up are discussed in the following sections. 86 Table 20: Responding hospitals with planned follow-up. Planned Follow-Up Frequency % Cumulative % Yes 17 29.8 29.8 No 40 70.2 100.0 E l' | D' l 'l l' Almost one-third of the hospitals with planned follow-up were located in the Southeast region (see Table 21). Table 21: Regional distribution of responding hospitals with planned follow-up (N = 57). Region Numther of Hospitals Percent of Total Hospi- esponding tals in Each Regm Southeast 6 10 South Central 2 13 Southwest 1 West Central 2 Greater Flint 1 13 East Central 2 10 North Central 1 7 Upper Peninsula 2 13 Total 17 11 87 | I 'l I S' The majority of hospitals with planned follow-up had between 25 and 99 beds (59%). The distribution of these hospitals by bed size is shown in Table 22. Table 22: Bed size of responding hospitals with planned follow-up (N = 57, [1 =17). Bed Size 100- 200- 300- 400- 6-24 25-49 50-99 199 299 399 499 500+ Number of 0 6 4 2 0 2 1 2 hospitals Discharges The average number of annual inpatient medical-surgical discharges ranged from a low of 60 to a high of 34,000. The mean number of client discharges was 6,544. The percentage breakdown of discharges is shown in Table 23. Table 23: Number of discharges for responding hospitals with planned follow-up (N = 57,11 =17). Number of Discharges NCFteosfpl-cligz‘iisls % Cumulative % Fewer than 1,000 3 21.4 21.4 l,00l-5,000 7 50.0 71.4 5,00l-10,000 0 0.0 71.4 10,001-15,000 2 14.3 85.7 15,001-20,000 1 7.1 92.8 20,001+ 1 7.1 100.0 ‘ Missing 3 88 The percentage oftotal annual inpatient Medicare discharges ranged from 20% to 95% (see Table 24). Mean Medicare discharges were 49.2%. Table 24: Percentage of total annual Medicare discharges for responding hospitals with planned follow-up (N = 57, n = 17). CI '[i !' [5! [Mil E l l ICI' l % Medicare Frequency Dis ch/zirg es Cumulative % 20 1 7.7 7.7 26—40 4 30.8 38.5 41-50 4 30.8 69.3 51-60 1 7.7 77.0 61-85 2 15.4 92.4 85+ 1 7.7 100.0 Missing 4 Hospitals were asked who usually planned to make the follow-up contact. More than 50% reported that the contact person was the discharge planner (see Table 25). Table 25: Planned follow-up contact person in responding hospitals (N = 57, n = 17). Contact Person Percent Discharge planner 53 Administrative personnel/secretary 18 Nonprofessional volunteer 18 , Discharge planner and either secretary or volunteer 11 89 W In more than 60% of hospitals, clients who received discharge planning services constituted the “pool" from which clients were selected for follow-up. Random selection of discharge planning clients was used in more than 40% of the hospitals (see Table 26). The one hospital that responded "other criteria“ indicated that if the client was elderly and had no care at home, she or he would receive follow-up after discharge. Table 26: Criteria used by responding hospitals for identification of clients for planned follow-up after discharge (N = 57, n = 17). How Selected % of Hospitals Random selection, all clients 11.8 Random selection of all discharge planning clients 41.2 Nonrandom selection, all clients 17.6 Nonrandom selection, all discharge planning clients 23.5 Other criteria 5.9 MBIDMEQHMQ The most frequent method of contact was by telephone (52.9%). This was followed by a combination of mail and telephone contact (35.3%). Twelve of the hospitals making telephone contact ([1 = 16) indicated they planned to contact 76% to 100% of their clients. One hospital indicated that, on average, telephone calls were made to 51% to 75% of clients. Three hospitals estimated that 90 between 10% and 25% of their clients were contacted by telephone. The mean percentage of planned follow-up by telephone was 77.8%. Six of the nine hospitals that indicated contact by mail planned to contact between 5% and 25% of clients. Three planned to contact between 76% and 100% of clients by mail. The mean percentage was 42.8%. Only one hospital indicated that it planned to do home visits for about 15% of its clients. Two hospitals responded that they planned to make facility visits after discharge for approximately 1% to 5% of their clients. WW Discharge plan adequacy and quality assurance were the most frequently stated reasons for planned follow-up after discharge (see Table 27). Table 27: Primary purpose of planned follow-up after discharge in responding hospitals (N = 57, n = 17). Purpose Frequency % Cumulative % Quality assurance 5 29.4 29.4 Plan adequacy 8 47.1 76.5 Maintain contact 1 5.9 82.4 Revise discharge plan 1 5.9 88.2 Determine client satisfaction 2 11.8 100.0 W 91 Only one hospital reported that it planned to maintain client contact for 22 days or more (see Table 28). Most hospitals planned either 2 to 7 days (31.3%) or 8 to 14 days (37.5%) of follow-up contact. Table 28: Average length of planned follow-up time after discharge in responding hospitals (N = 57, n = 16). Time Frequency % Cumulative % 1 day 1 6.3 6.3 2-7 days 5 31.3 37.5 8-14 days 6 37.5 75.0 15-21 days 3 18.8 93.8 22+ days 1 6.3 100.0 0' l El . D l CF I B I . . Thirty-one hospitals (55%) reported that they did not have a formal mechanism to monitor readmissions previously seen by discharge planners. Twenty-four did monitor readmissions. Of those 24 hospitals, 10 indicated they were notified by the admitting department staff. Nine hospitals said they were notified by utilization review personnel. Four hospitals indicated their discharge planners kept their own records to determine readmissions. One hospital 92 indicated it was notified by either nursing, the attending physician, or utilization review. Assignment Hospitals were asked whether discharge planners were assigned or designated by specialty, floor, and/or unit. Thirty-two hospitals (56.1%) indicated "no” to assignment; 25 hospitals (43.9%) responded "yes." DailLCaseLoad On average, a discharge planner was responsible for 39 beds. Hospitals indicated that daily case loads ranged from a minimum of 12 beds to a maximum of 90 beds. More than 80% of discharge planners had a daily client case load of 25 or fewer (see Table 29). Table 29: Discharge planner average daily client caseload in responding hospitals (N = 57, n = 54). Cases Frequency % Cumulative % Fewer than 15 24 44.4 44.4 16-25 21 38.9 83.3 26—30 7 13.0 96.3 31-40 1 1 .9 98.1 50+ 1 1 .9 100.0 93 Medicarejzaseload On average, Medicare client caseloads ranged from 20% to 99%. The mean percentage was 76.2% (see Table 30). Table 30: Percentage of discharge planners’ average daily caseload who were Medicare clients (N = 57, n = 50). % Medicare Caseload Frequency % Cumulative % 1-20 1 1.9 1.9 21-40 2 3.8 5.8 41-60 9 17.3 23.1 61-80 18 34.6 57.7 81-100 22 42.3 100.0 mm On average, the number of closed cases per month per discharge planner ranged from 3 to 177. The mean number of closed cases per month was 53 (see Table 31). Table 31: Number of closed cases per discharge planner per month (N = 57, n=4$. No. of Closed Cases/Month Frequency % Cumulative % 3-25 6 13.3 13.3 26-50 15 33.3 46.7 51 -75 15 33.3 80.0 75+ 9 20.0 100.0 94 CaseManagement Four questions in the discharge planning survey focused on case management services. For the purpose of this study, case management was defined as a hospital-based service that focused on ensuring appropriate and continuous care for selected clients after discharge. Fifty hospitals (88%) reported that they did not offer hospital-based case management services. Seven (12%) reported that they did provide case management services. Hospitals that did not provide case management services were asked whether or not case management had been considered. Of the 45 hospitals that responded, 20 (44%) reported that they had not considered case management programs. Twenty-five (56%) indicated that case management programs had been considered. When asked the main reason why case management had not been implemented, the most frequent response (40.5%) was that it was not a service targeted by hospital administration (see Table 32). WW The final question of the discharge planning survey asked hospitals what percentage of their discharge planners’ caseload needed case management services. The responses ranged from 5% to 80%. The mean percentage of need was 27.8% (see Table 33). 95 Table 32: Reasons why case management was not implemented (N = 57, n = 42). Why Gaff1 IlllllearrItzrg‘éeerz;ent Not Frequency % Cum‘ufllative Start-up costs 4 9.5 9.5 Operating costs 1 2.4 11.9 Not targeted 179 40.5 52.4 Community services adequate 7 16.7 69.1 Under review 5 11.9 81.0 Other (unspecified) 5 1 1.9 92.9 Don’t know 3 7.1 100.0 Table 33: Estimated percentage of responding hospitals’ annual caseload that needed case management (N = 57, n = 49). % asteggnegmifie Frequency % Cu malative Start-up costs 4 . 9.5 9.5 Operating costs 1 2.4 11.9 Not targeted 179 40.5 52.4 Community services adequate 7 16.7 69.1 Under review 5 11.9 81.0 Other (unspecified) 5 1 1.9 92.9 Don’t know 3 7.1 100.0 96 Survey Comments There were two opportunities in the survey for respondents’ comments. The first group of comments reiterated that functional concerns, communications concerns, and financial concerns were paramount for both clients and families from the discharge planners’ perspective. Several comments from more rural hospitals reflected the unique challenges that their discharge planners faced. Availability of extended care facilities was indicated as a problem. Nursing homes often were more than an hour away in all directions, making separation from family and cost of visits factors that had to be considered in the decision-making process. Also, cost of help, availability of equipment, and treatment in rural areas was mentioned as problematic. Home care was a priority and need; however, as indicated by one respondent, "Help is limited in our area, especially 24-hour live- in help.“ General comments focused on case management. For example, I have a real hard time with the concept of case managers in the hospital when SW/DP [social work/discharge planning] and UR [utilization review] are already performing the same functions. It seems that having case managers just adds another expensive level of people to identify problems who then refer [them] to SW/DP to do the work. It makes more sense to increase the number of SW/DP and UR people and avoid case managers altogether. Another respondent stated: I believe that case management—in a broad sense-is contradictory (unfortunately) to the current medical practices: increased specialization and increased fragmentation of our [health care] system. In acute medical hospitals, a case manager often experiences role conflict with the physician, [whose] job is to oversee coordination of care. Case manage- ment really requires a shift in our thinking--or increased direct reimburse- ment by third parties. 97 Last was a comment in which one discharge planner offered her or his opinion of how case management was perceived by the client: “Most elderly [persons] consider case management as becoming dependent on a system they usually want no part of.” Case Management Survey Two hospitals completed the case management survey (see Appendix E). One was from the Southeast region and had between 100 and 199 beds. The other was from the South Central region and had between 300 and 399 beds. One hospital indicated that case management was separate and distinct from discharge planning, and the other indicated it was not. Both hospitals responded that case management was available to selected clients in addition to discharge planning and not in lieu of it. In one hospital, case managers reported to Nursing Administration, and in the other to Quality Assurance/Unit Manage- ment. Geriatric Case Manager and Assistant Director 2AIUM were the job titles of the two persons completing the survey. All the case managers in both the hospitals had nursing degrees (RN/BA, RN, RN AD, and RN BSN). Both hospitals indicated they selected clients for case management based on age and diagnosis. Both hospitals indicated clients were contacted an average of five times per week and that the contact method was by telephone. Both hospitals indicated that case management was considered an administrative cost and that it was implemented because: 1. A large target population existed. 98 2. There was concern for client length of stay and the resulting expense to the hospital. 3. There were issues of quality client care. 4. Case management was an attempt to reduce readmission rates. Research Question 2: What are discharge planners’ perceptions of the concerns of elderly cardiovascular clients and their families before discharge? Perceived Client and Family Concerns Because of changes in how hospitals were reimbursed for services rendered, elderly cardiovascular clients were being discharged "quicker and sicker.” Given the shortened time frame for discharge planning, many clients and families had not had the time to think of home care plans or to explore the other options available to them. Although both clients and families often were aware they would need to make sacrifices to provide caregiving (and were willing to do so), they really had no way of knowing what awaited them after their family member was discharged from the hospital. Thus, both they and their families often found themselves facing impending discharge with considerable fears and worries. While the findings about client and family concerns were filtered through the perceptions of discharge planners, because of the central role that discharge planners play in identifying and addressing the concerns of elderly cardiovascular clients and their families, their perspectives were critical to developing and understanding the discharge planning process. Hospitals were asked, from a 99 discharge planner’s perspective, to rate the importance of 14 concerns to elderly cardiovascular clients and families before discharge (see Table 34). Afive-Ievel rating scale was used by discharge planners to rate their perceptions of client and family concerns before discharge. The scale ranged from extremely important to not important. Table 34: Means and rankings of discharge planners’ perceptions of clients' and families’ concerns (N = 57, n = 48). Concerns Client Family Mean Rank Mean Rank General medical concerns 3.76 6 3.53 10 Mechanics of discharge 3.16 12 3.53 9 Time spent with discharge planner 3.04 13 3.04 13 Options and/or destinations 3.90 3 3.95 5 Communication issues 3.89 4 4.04 2 Prognosis/functional status 4.19 1 4.39 1 Financial concerns 3.92 2 4.00 4 Psychosocial issues 3.32 10 3.45 11 Lifestyle changes 3.82 5 3.76 6 Family role changes/expectations 3.52 8 3.74 7 Dietary/nutritional issues 2.96 14 3.00 14 Therapy concerns 3.25 11 3.29 12 Famicharegiving 3.62 7 4.02 Home care training 3.41 9 3.60 Rating scale: 5 = Extremely important 4 = Very 3 = Moderately 2 = Very 1 = Not important 100 In dealing with the client and family, discharge planners played a "matchmaker" role as they assessed clients’ and families’ needs, goals, and objectives and then arranged for services to fulfill those needs. The identification of client and family concerns, which might be stated or implied and medical or nonmedical in nature, was an important part of the discharge planning process. How well fears, worries, and concerns were integrated into the discharge plan might be linked to both client and family outcomes after discharge. Supplementing the tables of discharge planners’ perceptions of client and family concerns isthe distribution of hospitals’ responses (see Tables 35 and 36). Most hospitals’ discharge planners rated the 14 client and family concerns as "moderately" or”very" important. More discharge planners rated aggregate family concerns as "extremely" important than they did aggregate client concerns. No discharge planners rated the following client and family concerns as "not important": home education/training, functional status/prognosis, life style changes. No discharge planners rated these concerns as ”not important” to families: family caregiving, discharge planning options/destinations, and family role changes/expectations. No discharge planners rated client psychosocial concerns as ”not important." 101 Table 35: Distribution of responding hospitals’ ranking of perceived client concerns (N = 57, n = 48). Importance Client Concerns Not Slight Moderate Very Extreme General medical 1 4 13 19 12 Mechanics of DP 2 10 19 14 4 Time with DP 2 13 19 11 4 Options/destination 1 2 20 12 14 Communication 2 3 12 13 19 Prognosis 0 0 9 21 19 Financial 2 2 13 4 23 Psychosocial 0 8 22 1 1 6 Life style changes 0 4 14 18 13 Family expectations 2 4 16 20 7 Dietary 3 12 21 10 3 Therapy 1 7 23 15 3 Family caregiving 1 3 15 24 6 Home care training 0 7 21 15 6 Total 17 79 229 215 1 39 102 Table 36: Distribution of responding hospitals’ ranking of perceived family concerns (N = 57, n = 48). Family Concerns Importance Not Slight Moderate Very Extreme General medical 2 3 18 15 9 Mechanics 2 5 15 19 8 Time with DP 4 9 20 13 3 Options/destination 0 3 12 18 16 Communication 2 2 9 15 21 Prognosis 0 0 7 16 26 Financial 2 3 11 14 19 Psychosocial 1 7 1 6 1 6 Lifestyle 0 5 1 5 19 Family expectations 0 7 1 1 18 13 Dietary 3 10 21 12 Therapy 1 8 20 16 Family caregiving 0 12 18 17 Home training 0 4 18 16 9 Total 17 69 207 220 168 Research Question 3. What is the relationship of discharge planners’ perceptions of concerns of elderly cardiovascular clients and their families to planned posthospital follow-up? Perceived Client and Family Concerns and Planned Follow-Up The researcher hypothesized that discharge planners’ perceptions of concerns of elderly cardiovascular clients and their families were related to 103 planned follow-up after discharge. For example, if a client was scheduled to be contacted by hospital personnel for a period of time after discharge, discharge planners might perceive that anxieties associated with general medical issues would be less than if no contact was planned. From a discharge planner’s perspective, follow-up contact might serve to bridge the transition between the hospital and the client’s next destination and to ameliorate some of the abruptness or fears associated with discharge. To determine whether a relationship existed between client and family concerns and planned follow-up, analysis of variance (ANOVA) tests were performed. Results were considered significant at an alpha level of .05 (see Tables 37 and 38). The statistical technique, ANOVA, was used to test the null hypothesis that the population means ofdischarge planners’ perceptions ofelderly cardiovascular clients’ and families’ concerns were the same regardless of planned follow-up after discharge. ANOVA was used to determine whether there was reason to believe any population means were unequal. The observed significance levels for perceived client concerns about general medical issues (:2 = .0283) and perceived family concerns about communication issues (:2 = .0192) indicated that it was very unlikely that one would see such a large E-ratio when the null hypothesis was true. Therefore, for these two concerns, the null hypothesis was rejected. 104 Table 37: Analysis of variance: Perceived client concerns by planned follow-up (N = 57, n = 48). Client Concerns sslms E-Ratio E—Prob. General medical 4.6219 5.1 186 .0283” Mechanics of DP .9365 .9385 .3317 Time with DP 1.6702 1.6974 .1990 Options/destination .2710 .3017 .5854 Communication 3.6988 3.1080 .0844 Prognosis 1.9932 3.8370 .0561 Financial .8107 .6227 .4340 Psychosocial 2.2692 2.8410 .0988 Life style changes .0694 .0790 .7799 Family role changes .0021 .0021 .9635 Nutrition/diet .0417 .0418 .8389 Therapy .8438 1 .1 363 .2920 Family caregiving 2.6444 2.6444 .0606 Home care training 1.5264 1.9079 .1739 *Significant at p < .05. 105 Table 38: Analysis of variance: Perceived family concerns by planned follow-up (N=51n=4&. Family Concerns 511 films E-Ratio E-Prob. General medical 1 1.8075 1.81 15 .1848 Mechanics of DP 1 .3530 .3328 .5668 Time with DP 1 1.6702 1.6270 .2084 Options/destination 1 .1684 .1981 .6583 Communication 1 6.2143 6.2143 .0192* Prognosis 1 .2282 .4223 .5190 Financial 1 .6146 .4891 .4878 Psychosocial 1 .3247 .3226 .5729 Life style changes 1 .1219 .1220 .7284 Family role changes 1 .1609 .1516 .6988 Nutrition/diet 1 .0000 .0000 1 .0000 Therapy 1 1.7604 2.1223 .1520 Family caregiving 1 1.9502 2.6166 .1 124 Home care training 1 1.2666 1.5428 .2232 *Significant at p < .05. To ascertain the strength and nature of the linear relationship between discharge planners’ perceived concerns of elderly cardiovascular clients and their families and planned follow-up, Pearson correlation coefficients (r) were computed (see Tables 39 and 40). By definition, in this measure of association, variables were positively correlated if cases with low values for one variable also 106 tended to have low values for the other, and cases with high values on one also tended to be high on the other. Table 39: Pearson correlation coefficients: Perceived client concerns and planned follow-up (N = 57, n = 48). Client Concerns 1: Significance General medical .31 .03* Mechanics of DP -.14 .33 Time with DP .18 .20 Options/destination -.07 .59 Communication -.25 .08 Prognosis .27 .06 Financial -.1 1 .43 Psychosocial -.24 .10 Life style changes -.04 .78 Family role changes -.01 .96 Nutrition/diet .02 .84 Therapy .16 .28 Family caregiving -.27 .06 Home care training .20 .16 *Significant at p < .05. 107 Table 40: Pearson correlation coefficients: Perceived family concerns and planned follow-up (N = 57, n = 48). Client Concerns [ Significance General medical .19 .19 Mechanics of DP -.08 .57 Time with DP .18 .21 Options/destination .06 .66 Communication .33 .02* Progn_osis -.09 .52 Financial -.10 .49 Psychosocial .08 .57 Life style changes .05 .73 Family role changes -.06 .70 Nutrition/diet -.00 1 .00 Therapy .21 .14 Family caregiving .22 .11 Home care training .18 .22 *Significant at p < .05. The significance levels for discharge planners’ perceptions of the importance of general medical issues to elderly cardiovascular clients (I: = .31, p = .03) and communication issues to families of elderly cardiovascular clients (r: .343, p = .02) indicated that the null hypothesis-that there is no linear relationship between these perceived concerns and planned follow-up--was rejected. The Pearson correlation coefficients (r) for these two concerns ([ = .31 108 and r = .33, respectively) indicated that there was a positive association with planned follow-up and that the strength of the association was moderate. CHAPTER V SUMMARY OF FINDINGS, DISCUSSION, CONCLUSIONS, AND RESEARCH IMPLICATIONS Summary of Findings and Discussion This chapter provides a summary and discussion of discharge planning and case management programs in Michigan, and of discharge planners’ perceptions of the concerns of elderly cardiovascular clients and their families. The chapter concludes with implications for research theory and practice. The researcher’s purpose in this study was to conduct a survey of Michigan’s acute care hospitals to identify and describe the discharge planning and case management services provided, and to document discharge planners’ perceptions of the concerns of older cardiovascular clients and their families before discharge. Planned follow-up in relation to the perceived concerns of cardiovascular clients and their families also was examined. The research questions were: 1. What are the structural, process, and outcome characteristics of discharge planning and case management programs in Michigan’s acute care hospitals? 109 110 2. What are discharge planners’ perceptions of the concerns of elderly cardiovascular clients and their families before discharge? 3. What is the relationship of discharge planners’ perceptions of concerns of elderly cardiovascular clients and their families to planned posthospital follow-up? Two surveys were developed by the researcher to answerthese questions about discharge planning and case management programs in Michigan (see Appendices D and E). This information previously was not available. No agency or individual was able to provide information on hospital discharge planning practices for even a sample of hospitals in Michigan. In addition to descriptive questions, discharge planners were asked to rate their perceptions of the importance of 14 concerns to elderly cardiovascular clients and their families before discharge. Analyses of variance (ANOVA) were performed for each of these client and family concerns to determine whether a relationship existed between discharge planners’ perceptions of concerns and planned follow-up programs. Pearson correlation coefficients (r) were computed to determine the nature and strength of any relationships. [1' I El . 5 Hospitals that participated in the survey (N = 57) mirrored Michigan’s geographic diversity. In terms of numbers of hospitals, the Southeast region, with nearly one-half ofthe state’s population and one-third of the state’s hospitals, was 111 the most frequently represented. The discharge planning function within Michigan’s hospitals also was characterized by diversity. Programs differed as to what discharge planning was called within the hospital, to whom the discharge planner reported, who received the services of this person whose primary responsibility was discharge planning, and who was expected to need case management after discharge. Although most discharge planning departments had social work or social services in their department name (55%), participating hospitals used 12 different departmental names to identify their function. There also was variation as to where discharge planning was found within the hospitals’ organizational structure. The most common reporting relationships for the discharge planning department were with administration, nursing, social work, or utilization review. In trying to assess what percentage of annual inpatient discharges received discharge planners’ services, again there was a wide range of responses, from 4% to 100%. Regardless of whether a hospital offered case management or not, there was no consensus about the need for case management services, either hospital or community-based. When asked to estimate the need for case management, the hospitals’ responses ranged from 5% to 80% of discharge planning clients. How a discharge planner spent his or her time further reflected the diversity inherent in the discharge planning process in Michigan’s acute care hospitals. The percentage of time spent in coordinating community services ranged from 0% to 60%, with 37% of hospitals indicating discharge planners spent between 21% 112 and 30% of their time on coordination of community services. Administrative activities took up from 0% to 45% of discharge planners’ time. Most hospitals indicated that discharge planners did not spend more than 30% of their time on paperwork-related activities. Time spent on assessment of clients and families ranged from 0% to 70%. Time spent on advising and counseling clients and families ranged from 0% to 60%. This is not to saythat Michigan's discharge planning programs had nothing in common. Similarities were evident in how clients were identified to receive the services of a discharge planner. Nurses and doctors, followed by social workers, played a key role in client identification. The primary indicator of need in 56% of the hospitals was functional status. Whereas the literature was divided as to what educational background was best for a discharge planner, in this study most discharge planners had a social work background (66%). More than half of these social workers had masters degrees in social work (MSW). Of the nurse discharge planners, 39% held an RN Bachelor of Nursing degree. Most hospitals indicated that their discharge planners received on-the-job training with an experienced discharge planner/mentor for at least 2 to 7 days, in addition to access to a procedure manual. Most hospitals did not assign discharge planners by specialty, floor, or unit. Most hospitals had in common that approximately half of their discharges were Medicare clients. Correspondingly, most discharge planners’ caseloads were more than 75% Medicare clients. Forty-four percent of hospitals had a formalized system for identifying clients who were being 113 readmitted into the hospital. In hospitals with planned follow-up, 53% of the planned follow-up contacts were made by discharge planners. Not surprisingly, a time analysis indicated that the largest percentage of discharge planners’ time was devoted to discharge planning. More than 58% of the hospitals reported that their discharge planners did not spend time on peer review, utilization review, or supervisory functions. Surprisingly, 16% of the hospitals indicated that their discharge planners spent no time in meetings or committee work! BIannedEollowfip The hospitals with planned follow-up were distributed throughout the state and were representative of the population. Most were located in the Southeast region; however, each region had at least one hospital with planned follow-up. The majority of hospitals with planned follow-up had between 25 and 99 beds. The mean bed size was slightly larger in hospitals with planned follow-up: 187 beds compared with the sample population mean of 184. Mean percentages of Medicare discharges were 49% for hospitals with planned follow-up and 52% for the sample population. Of the 17 hospitals with planned follow-up, most contacted their clients by telephone (53%) or by the combination of telephone and mail contact (35%). Two hospitals indicated they had staff who planned to make visits to facilities where they had referred clients. Only one hospital planned any follow-up visits to clients’ homes. The most frequent length of follow-up time was 8 to 14 days (38%), 114 followed by 2 to 7 days (31%). Most clients (41%) for whom follow-up contact was planned were selected randomly from clients who received discharge planning services. The primary purpose of contact was to determine the adequacy of the discharge plan. CaseManagemenLSunLex A post card was enclosed with the discharge planning survey, which asked hospitals if they provided case management services (see Appendix B). Persons receiving hospital-based case management services, by definition, were followed for an indefinite period of time, based on individual client needs. A hospital that responded positively was sent a supplemental case management survey (see Appendix E). Hospitals also were asked whether they provided case management in the discharge planning survey. Incongruities resulted between the responses to the post cards and the responses to the discharge planning surveys about the availability of case management programs. These pointed to a deficiency in data-collection methodology. One probable source of the confusion was that, whereas case management was defined in a later section of the discharge planning survey, it was not defined on the post card. The net result was that four hospitals offered hospital-based case management services. However, two of the four had just begun their programs and were not able to complete the case management survey. 115 When discharge planners were asked their perceptions of the concerns, fears, and worries of elderly cardiovascular clients and their families before discharge, prognosis/functional status ranked highest in importance for both groups. Diet and nutritional issues were perceived by discharge planners to be of least concern to both clients and their families pending discharge. On a Likert scale of importance (5 = extremely important, 4 = very, 3 = moderately, 2 = slightly, 1 = not important), after prognosis/functional status (4.39), discharge planners perceived that the most important family concerns were communication issues among clients, families, doctors, and other members of the health care team (4.04); caregiving issues (4.02); and financial concerns (4.00). After dietary/nutritional issues (3.00), the least important concern for families, as perceived by discharge planners, was the amount of time spent with the discharge planner (3.04). For clients, after prognosis/functional status (4.19), discharge planners perceived that the most important concerns were financial considerations (3.92), discharge options or destinations (3.90), and communication issues (3.89). Perceived as least important to clients were dietary issues (2.96), time spent with a discharge planner (3.04), and issues concerning the mechanics of discharge (3.16). One possible explanation for the low ranking for dietary and nutritional issues is that, with discharge imminent, the immediacy of the situation 116 overshadowed or minimized nutritional/dietary concerns. Another explanation is that dietary concerns were addressed in other ways. Proctor et al. (1992) studied the adequacy of discharge plans by interviewing clients and families within 24 hours after discharge. They found that, in explaining client satisfaction after discharge, families were more influenced by process issues, whereas clients had a more person-centered focus. Discharge planners in the current study perceived the process issue, ”the amount of time spent with the discharge planner,” to be of “moderate” importance to families (3.04). Discharge planners’ perceptions of the mean importance of communication issues to families (4.04) and prognosis/functional status issues for clients (4.19) were more consistent with the findings of Proctor et al. In comparing the rankings of discharge planners’ perceptions of client and family concerns, with the exception of general medical issues (e.g., pain management and medication side effects) and lifestyle changes, family concerns were afforded a higher mean ranking. The greatest disparity between client and family concerns occurred with perceived concerns aboutfamily caregiving and the mechanics of discharge. Discharge planners’ perceptions of family caregiving concerns resulted in a mean importance level of 3.62 for clients and 4.02 for families, a difference of .40. Discharge planners’ perceptions of worries about the mechanics of discharge were 3.16 for clients and 3.53 for families, a difference of .37. 117 To determine whether there was any relationship between discharge planners’ perceptions of the concerns of elderly cardiovascular clients and their families and planned follow-up, ANOVA tests were performed. Two concerns were found to be related to planned follow-up. A significant relationship with planned follow-up was found for discharge planners’ perceptions of the importance of general medical issues for clients (9 = .0283). A significant relationship was found between discharge planners’ perceived importance of communication issues forfamilies and planned follow-up (p = .0291 ). Thus, when cases in this study were classified by planned follow-up, the means of discharge planners’ perceptions of the importance of client and family concerns were not all equal. Forthe two concemsugeneral medical issues for elderly cardiovascular clients and communication issues for their families— planned follow-up did make a difference in the mean ranking of importance, as perceived by discharge planners. Pearson correlation coefficients (r) were computed to determine the nature and strength of the linear relationship between discharge planners’ perceptions of client and family concerns and planned follow-up. In this study, discharge planners’ perceptions of general medical concerns for clients (I: = .31, p = .03) and communication issues for families ([ = .33, p = .02) were found to have a moderate, positive relationship with planned follow-up. The association between perceived client concerns about general medical issues and planned follow-up suggests that the higher discharge planners rank the perceived importance of 118 general medical issues for clients, the greater the likelihood that the hospital has planned follow-up. The converse also is suggested: Discharge planners in hospitals with planned follow-up are more likely to perceive that client concerns about general medical issues are more important than are discharge planners in hospitals without planned follow-up. The association between perceived family concerns about communication issues and planned follow-up indicates that discharge planners in hospitals with planned follow-up are more likely to perceive that communication issues for families are of greater concern. Conclusions Dischargeflannjngfiumv This exploratory study provided descriptive findings on discharge planning programs in Michigan’s acute care hospitals. Discharge planners’ perceptions of the concerns of elderly cardiovascular clients and their families before discharge were examined. With only two Michigan hospitals identified with established case management programs, no conclusions were drawn about case management in Michigan. However, there were case management programs in the ”under consideration" or "just beginning" phases that should be the subject of future research. The survey results suggested that hospitals in Michigan were characterized by diversity whether the criteria were structural, process, or outcome issues. The environments from which discharge planning clients were discharged ranged from small rural hospitals with 6 to 24 beds to large 1 19 metropolitan teaching hospitals with more than 500 beds. The discharge planning function within Michigan’s acute care hospitals mirrored this diversity. This study corroborated findings in the discharge planning and case management literature that researchers have been unsuccessful in gaining consensus as to what discharge planning is and is not (Blumenfield, 1986; James, 1987; Rehr, 1986). There is no widespread agreement in Michigan’s hospitals on the level of skill and sophistication discharge planning requires; its target population; its boundaries; and the roles of client, family, social worker, nurse, and physician. Therefore, it is difficult to profile or describe “typical" hospital discharge planning in Michigan’s acute care hospitals. The study findings pointed to differences across programs that transcended such environmental factors as bed size, geographical location, and the discharge planners’ reporting relationships. Because little empirical research has been done in other states or on a national level, one cannot conclude whether Michigan’s diversity is a shared characteristic. In addition, diversity among Michigan’s discharge planning/discharge planners is coupled with ambiguity as to who discharge planners are, and what their role is within the hospital and on the health care team. The complexity of defining the role of the discharge planner is a reflection of the complex hospital environment. One can conclude that the hospital’s structure, goals, technology, ideology, and adherence to the medical model might even be more powerful than professional perspective in defining discharge planning services (Iglehart, 1990). 120 E . ICI'I IE .I C Consistent with Glennon and Smith’s (1990) study of actual concerns of rehabilitation clients, discharge planners in the current study perceived that concerns about prognosis and functional status ranked highest in importance for both elderly cardiovascular clients and their families before discharge. The primary concern of the client, as perceived by discharge planners, was to be able to get back to at least a minimum level of prior functioning. Perceived client concerns were practical: What will be the outcome of this admission, and what is my life going to be like now? Before discharge, elderly cardiovascular clients were faced with functional changes in their activities of daily living. Discharge planners reported that they desired to return home and to be as independent as possible, while at the same time knowing that they needed help. The family caregiving literature supported that the return home, continued independence, and not wanting to become a burden were important concerns for both the client and his or her family (Albert, 1990; Brody, 1985; Cicirelli, 1990, 1991; Johnson 8 Troll, 1992; Whitbeck et al., 1994). Clearly, if the client does not return to his or her previous living situation and/or requires a different level of care, it affects all involved. Discharge planners’ perceptions in this study lent support to the findings in the literature that families were most concerned about changes in the client’s functional abilities and what they would have to do to keep that family member at home. Specifically, what 121 family role changes, financial burdens, and time commitments are involved once the client is discharged? That discharge planners perceived financial issues and options] destinations to be the second and third most important sources of concern, worry, and fear for clients was not surprising. Escalating health care costs, coupled with deficiencies in Medicare coverage, heighten fears about insurance not covering hospital costs, nursing home costs depleting savings, and the ability to afford prescribed medications. The family caregiving literature reflects concerns of clients regarding losing life savings and being a financial burden to their families (Brody, 1985; Cicirelli, 1990; Johnson 8 Troll, 1992). Until Medicare coverage is more all-inclusive, one can conclude that there will continue to be cases in which clients actually refuse care if it is not covered by insurance. The high ranking of communication issues by discharge planners reflected its perceived importance to the overall coordination of care before and after discharge. Effective communication is needed among all the various channels to ensure that the client receives appropriate assistance during his or her transition from the acute care setting. Communication among family members, and between family members and health care professionals, plays a particularly crucial role during discharge planning. The literature acknowledged inherent difficulties in effective communication among the participants in the discharge planning process (Johnson 8 Fethke, 1985; McNamara, 1985; Murray et al., 1982; Proctor et al., 1992; Tuzman 8 122 Cohen, 1992). These included the stress of dealing with illness, the intimidating physical environment of the hospital, and the unfamiliar medical terminology and jargon. Good communication, however, if effective, can reduce the unknown aspects of posthospital care and thus reduce client and family anxiety. Practically, good communication can help prevent inappropriate discharge plans and hospital readmissions, and can improve both client and family outcomes. Discharge planners’ perceptions of the importance ofcommunication issues also underscored that attention to process is important. This was evidenced in the correlation between communication and relationship with health care profession- als and patient satisfaction found in the discharge planning literature (Morrow- Howell et al., 1991). E 'ICI‘I IE 'IC andElannedEollowAJp The researcher hypothesized that discharge planners’ perceptions of the concerns of elderly cardiovascular clients and their families are related to planned follow-up. lf clients and families knew there would be contact after discharge, perhaps, from the discharge planners’ perspective, that would lessen fears or worries about the posthospital environment. Contact after discharge might give the caregiver an opportunity to review aspects ofa home care procedure or verify that the client is adhering to his or her prescribed regimen. Contact might enable a client and/or a family member to vent frustrations, to share feelings of being overwhelmed, or to discuss inadequacies in the discharge plan. 123 One can conclude from the survey results that discharge planners’ perceptions of client and family concerns were related to planned follow-up in two areas. Perceived mean importance of general medical issues to clients were related to planned follow-up at an attained significance level of p = .0283. Perhaps discharge planners perceived that planned follow-up contact acted as a bridge or safety net between the hospital and home. As such, planned contact helped to allay clients’ fears of leaving the technologically sophisticated environment of the hospital--with instant availability of clot busters and nitroglycerin. Discharge planners’ perceived mean importance of communication issues to families of elderly cardiovascular clients were related to planned follow- up at an attained significance level of p = .0192. Perhaps discharge planners perceived that planned follow-up allowed the channels of communication to remain open between the family and hospital personnel, and thus reduced the anxiety associated with an abrupt cut-off from the resources of the health care team. A moderate, positive relationship was found between discharge planners’ perceptions of the importance of general medical concerns to clients and planned follow-up ([ = .31, p = .028). This suggests that, in those hospitals with a greater likelihood of planned follow-up, the higher discharge planners perceived the mean importance of general medical issues to clients. These findings lend support to the research by Rhoads et al. (1992), who evaluated discharge planning outcomes by visiting clients at home within 2 weeks after discharge. Rhoads et 124 al. found clients who were fearful, apprehensive, and worried about how to perform the at-home medical procedures (e.g., dressing changes and pain management techniques) demonstrated to them before discharge, as well as how they were going to deal with the side-effects of not taking medications they could not afford. The positive relationship between discharge planners’ perceptions of the importance ofgeneral medical concerns to clients and planned follow-up also was consistent with the Rand researchers’ findings that clients were indeed being discharged "sicker and quicker” from the hospital setting (Kosecoff et al., 1990). The relationship between discharge planners’ perceptions of the importance of communication issues to families and planned follow-up also was moderate and positive ([ = .33, p = .019). Thus, the greater the likelihood of planned follow-up after discharge, the higher discharge planners perceived the mean importance of communication issues to families. This finding suggests that discharge planners in hospitals with planned follow-up learn first-hand of the importance to families of effective communication among clients, families, health care professionals, and physicians all along the continuum of care. As families monitor and adapt to anticipated and unanticipated changes experienced after discharge, ongoing communication remains essential to the overall provision and coordination of care. Research Implications This study provided preliminary information to describe the discharge planning and case management practices of acute care hospitals in Michigan. AIlh vali< dar cas clle COT we CEI de~ W3 sit the DST: with relnt II’lllo 39035 125 Although only two hospitals responded to the case management survey, they validated the emergence of case management programs, as well as the lack of clarity among health care professionals as to the role of discharge planners and case managers in the care management of chronically ill elderly cardiovascular clients. The survey also measured discharge planners’ perceptions of the concerns of elderly cardiovascular clients and theirfamilies. Although the findings were filtered through the perceptions of discharge planners, because of the central role that discharge planners play, their perspectives were critical to developing and understanding the discharge planning process. ll'l' [S'E'l One message conveyed in this study was that families of elderly cardiovascular clients and discharge planning were inextricably intertwined. This was consistent with the conclusion of Morrow-Howell et al. (1991) that, in situations in which families were not involved in developing discharge plans, clients’ needs were not well met following discharge. Discharge planners’ perceptions of the importance of family concerns ranked above clients’ concerns with only two exceptions: general medical issues and lifestyle changes. This reinforced the important role of family in the discharge planning process. That discharge planners perceived general medical issues as more important for clients than families suggested that clients, who had the most access to the health care team, might have had concerns that were not 126 satisfactorily addressed by the medical staff. This pointed to the important role of the physician in discharge planning and perhaps to shortcomings in the dialogue between doctor and client. The perceived mean importance of lifestyle changes and general medical issues to clients also confirmed the findings of Proctor et al. (1992) that clients’ fears, worries, and concerns were more person- than process-centered. This study also suggested that one way of anticipating unmet needs after discharge is to look at how well client and family concerns have been addressed and integrated into the discharge plan. From the discharge planners’ perspective, those concerns or questions expressed by the client orfamily might point to topics that had not been covered adequately before discharge. By documenting and addressing predischarge concerns, discharge planners might be better able to facilitate family conferences, and ultimately might be able to improve the quality of client and family outcomes following hospital discharge. Another study implication was that inconsistency and ambiguity among hospital-based discharge planning programs might be a reason (albeit circular) why a national professional organization of discharge planners has not evolved. Toward that end, researchers and service providers need to address questions like: What is the preferred educational preparation for a discharge planner? In the survey, the role of both nurses and social workers as discharge planners was identified. Some respondents indicated they preferred to have nurses in the role of discharge planners and case managers because of the diverse abilities of 127 nurses to assess and intervene with clients on many levels, including physical assessments, psychosocial assessments, and the identification of clients’ needs at home. Other program directors indicated they preferred social workers in the role of discharge planners because of the social workers’ strong background in financial and psychosocial assessments. Still other program directors employed no professional staff in the role of discharge planner, perhaps because of the belief that staff could be taught discharge planning on the job, without formal educational preparation, or because of budgetary constraints. These findings support the need for the development of professional standards of practice for discharge planning, including the qualifications for entry into the specialty. Ell'El' l I. l' Although Democrats conceded defeat on health care reform for this session of Congress (Rogers 8 Stout, 1994), lawmakers in both parties vowed quickly to return to the issue next year. Regardless of what is happening or not happening in the arena of health care reform, the current system is changing fast. These changes affect both those who use the health care delivery system and health care providers as well. Because the acute care system is looking for new sources of revenue, Dennis Beatrice, vice-president of the Henry J. Kaiser Family Foundation, predicted an increase in the integration of acute care and long-term care (Respite Report, 1994). He indicated that hospitals are looking for new market opportunities as they face more competition forfewer clients. In light of the trend 128 toward mergers that is occurring among hospitals, Stephen Somers, associate vice-president of the Robert Wood Johnson Foundation, proffered that a hospital’s best defense is to have a sound economic base upon which to operate (Respite Report, 1994). As demonstrated above, there is an immediate need for program-specific research on discharge planning and emerging case management programs. The cost/benefits of the programs, clients’ outcomes, and the roles of discharge planners, case managers, and families are just a few areas that need to be explored. One significant contribution of research on the costs and quality outcomes of discharge planning programs would be the justification, to hospital administrators and the architects of health care reform, of the importance of the development and testing of innovative programs. Supporting these programs both philosophically and financially to continue program success would then become an importantjoint role of nursing and social work executives and hospital administrators, the public, and government health care officials. Euturefleseamb The literature indicated that discharge planning is supposed to be client- centered (Gehl 8 Lantzy, 1990; Glennon 8 Smith, 1990; Hartigan 8 Brown, 1985a; Rhoads et al., 1992). However, from whose perspective are the clients’ posthospital needs determined? Do discharge plans reflect the discharge planner’s own needs, orthe hospital’s needs, or those of the client, or the family, or some combination of needs? Who provides definitions of appropriate or safe? 129 Do discharge planners really know who their clients are? Have they really heard what they are saying? Do they understand what their clients are doing, what they want, and what they can manage? What is the congruity between discharge planners’ perceptions of client concerns and their own concerns? As Gehl and Lantzy (1990) found in their study of infant discharges, discharge instructions and the planning process often evolved from the health care providers’ perceptions and not necessarily from the parents’ identified needs and perceptions. Much more research is needed that identifies programs that are effective at surfacing the concerns of clients and families before discharge, to improve client and family outcomes after discharge. More comparative research on actual client and family concerns and discharge planners’ perceived concerns will provide valuable information. Also, more research is needed on the effect of discharge planners’ perceptions of client and family concerns on the discharge planning process. For example, do discharge planners’ perceptions ofconcems affecttheir expectations of families or what questions they ask families? Do their perceptions affect how they define the range of available choices to clients and families, as well as their consequences? Correspondingly, problems of expectations of clients and families, which underlie complex discharge planning, also need to be studied. In addition to future research that examines how best to elicit client and family input into discharge planning activities, more research is needed on the family role in elder care and the exploration of interventions to enhance the family 130 role in the discharge planning process. Ongoing research continues to document the important role of the family in the care of the disabled elderly and in maintaining the elderly person in the community (Brody, 1985; Brody et al., 1994; Cicirelli, 1988, 1990, 1991; Hagestad, 1986; Longino, 1990; Moss et al., 1985; Shanas, 1979; Whitbeck et al., 1994). However, the demands of caregiving and the influence on the caregiver and the family as a whole persist as a source of much concern (Brody, 1985; Longino, 1990; Montgomery 8 Borgatta, 1989; Whitbeck et al., 1994). The numbers of chronically ill older persons needing at least minimal help continue to increase, smaller families continue to spread the burden of care among fewer people, and many children who are potential helpers continue to grow older themselves (Brody, 1985; Kane et al., 1984; Markson, 1992; Noelker 8 Wallace, 1985). Research also is needed to address the questions raised by the increased role of the family in the posthospitalization period: How do discharge planners view family members? For example, do they see them as potential caregivers, or as part of a family system responding to a family crisis? How should family needs and concerns be assessed? How broad should a family assessment be? How does a family assessment ensure that willingness, motivation, understanding, and know-how are present? How should differences between older clients and family members about service needs be handled? How are inconsistencies among family goals, community resources, and a client’s character to be resolved? How do ethnic and cultural factors affect family 131 involvement in the care of elderly persons? How is discharge planning affected by a family’s understanding of chronic illness and its implications, by a family’s health beliefs, or by a family’s thoughts about planning in general? How do changing demographic and work patterns affect the role of the family in discharge planning (American Health Planning Association, 1992; Brody et al., 1987; Brody et al., 1994; Cicirelli, 1988; Markson, 1992; Stoller 8 Pugliesi, 1989)? The literature suggested that even the most stable families and well- informed clients might feel anxious and fearful about arranging posthospital care, and that these stresses might cause resistance to discharge planning activities (Abramson, Donnelly, King, 8 Malick, 1993; Johnson 8 Fethke, 1985; Markson, 1992; Morrow-Howell et al., 1991; Rossman, 1977). The early recognition of possible disagreements and the resolution of conflicts obstructing decision making might be among the most clinically demanding tasks for discharge planners. Yet little is known regarding the frequency and nature of such conflicts, the sources of conflicts, or the effectiveness of various intervention strategies. Discharge planners encounter clients and families at critical points in a hospitalization. More research is needed about the ability of the family system to respond adequately to impending discharge. What prior problem-solving techniques dofamilies bring to the discharge planning decision-making process? How do differences among family members in clarity of communication, in the extent to which families can express both positive and negative emotions, and in the capacity for role flexibility affect discharge planning decisions? If 132 disagreements indeed are part of the complexity of discharge planning, the discharge planner needs to be prepared to assess the potential for conflict in a given case and to develop strategies for intervention to facilitate resolution and timely discharge. Effective resolution of family conflicts might provide better outcomes for clients and families while at the same time meeting institutional and regulatory demands. The findings from this study corroborated those in the literature that most discharge planners’ educational preparation is in either nursing or social work (Blumenfield, 1986; Ethridge 8 Lamb, 1989; Rehr, 1986; Zarle, 1987). However, if most discharge planning disagreements involve family members, then intervention approaches need to incorporate knowledge and skills specifically related to working with families. Given the important role of the family and the need to engage the family in the discharge process, more research is needed on the role of family studies in the educational preparation of discharge planners. Also, little research has been conducted on the role of family counseling in discharge planning. Rather than counseling having a more traditional therapeutic goal, its focus here would be to help the family solve a situational problem. Thus, instead of viewing family members during discharge planning as uncooperative, pathological, or dysfunctional, serious illness would be acknowledged as a family crisis that grows logically out of the disruption caused by the effect of chronic illness on the role expectations and role performance of family members (Brody et al., 1987; Creasey et al., 1990). 133 More research also is needed on the evaluation of discharge planning and client and family outcomes after discharge from the hospital. In this study it was found that 17 out of 57 hospitals in Michigan (mostly in the 25-99 bed category) planned follow-up. This supports Quinn’s (1992) finding that most discharge planning departments did not follow clients after discharge; thus, little is known about the stability or adequacy of discharge plans. More research is needed to determine whether there is a relationship between hospital-based follow-up and improved outcomes. For example, is there a relationship between follow-up and readmissions? How should clients be selected for follow-up? Who should make the follow-up contact? To begin to address some of these questions, common criteria and evaluation methods are needed so that future researchers can evaluate discharge planning and case management programs using the same methods in each hospital setting. Last, specific questions on discharge planning/case management emerged as a result of the current study that warrant further research. These are particularly relevant to families within the context of DRGs, health care reform, and the dynamic health care environment. 1. What is the role of personnel who facilitate discharges? Are there special roles and responsibilities for those who address the most complex discharges? 2. Is some on-going assessment and planning needed after the client leaves the hOSpital? Should the hospital’s responsibility in coordinating discharge av dis l0l effe Slim 134 care continue for a period of time after discharge to reduce the risk of poor outcomes? Is it realisticthat the hospital discharge planner can provide after-care from the acute care setting? 3. What internal processes and structures are hospitals designing to deal with discharge problems in a systematic and timely way? Is there a relationship between discharge planning program structure and client and family outcomes? Between process and outcomes? 4. What role do the family and other informal supports play in discharge planning for chronically ill elderly clients? 5. How well are clients and families prepared in terms of developing realistic expectations for immediate and long-term physical and social functioning? What is the quality of the preparation and support that clients and families receive for the posthospital period? 6. Whattraining, counseling, and special respite assistance should be available for families who are heavily invested in a family member’s care afler discharge? 7. Should family members be paid for providing postdischarge services to elderly chronically ill relatives? 8. How should services provided by families be figured in cost- effectiveness studies? 9. How can the support provided by families be decreased? When should such support be decreased and agency services offered instead? poslh collec dlsd anal Intel moc Whe Imm I980 ([0 m assist MCI R9390 renegc 135 10. How available are formal support systems to optimize clients’ posthospital outcomes? 11. What discharge planning/case management data need to be collected to guide management decisions and health policy initiatives? El'lll'l' The researcher’s goal in this study was to envision the "wholeness" of discharge planning in Michigan hospitals along the continuum of care by analyzing its principal components. A human ecosystems perspective provided a means of viewing the whole by seeing the relationship of its parts. The discharge planning eco-model (see Figure 1) illustrated the dynamic interactions occurring during discharge planning that necessitated a holistic model. The model purposely did not place the client and/or family in the center. Whereas the appropriate involvement of client and family might be the most important process in discharge planning, societal emphasis on the use of health resources and the attention paid to costs tend to move the client and family away from the center of the care process. From an ecosystems perspective, discharge planning is conceptualized as assisting elderly cardiovascular clients and their families with the central task of readjusting their roles and expectations in the face of hospital discharge. Responding to the crisis of illness requires that clients and families reexamine and renegotiate personal and interpersonal role expectations in light of changing circumstances. The model conveys that the consequences of an acute care 136 experience, for both clients and families, are not limited to physical consequences but extend to emotional, social, and even spiritual areas of functioning. Thus, one essential base for building a realistic discharge plan is a clear understanding of the effect of chronic illness on clients and families, including the psychological, social, environmental, and financial aspects of their life situation. One indicator of this effect is the information sought or concerns expressed before discharge by both clients and families. Also, the model conveys that the domain of the discharge planner is the interface area that includes both the coping behaviors of people and the qualities of the impinging social and physical environments (Germain, 1990). Specifically, the discharge planner deals with client care issues, family caregiving issues, and community care issues; administrative requirements and the limits of Medicare coverage; and financial/legal issues, including Medicaid eligibility, judicial system delays, and unwillingness of agencies to accept Medicaid clients. Viewed from an ecological perspective, discharge planning is not a simple, one-step set of routine and standardized procedures that anyone can devise, master, and use in any context. Instead, it is a process that requires the identification of the participants in the process, parameters of their roles, performance expectations, and boundaries of rights and obligations; clear definitions of objectives; collection of data and analysis of their relevancy; and the study of possible alternatives, with evaluations of their consequences. Inherent in the process are multidimensional goals (client, family, health care 137 professionals, payer, community) associated with the decision outcome. Each of these is affected bya given client-related decision. The decision-making process itself affects each of the participants differently. It depends on the condition of each participant, the stress and anxiety of the client, and the distress that the family feels, as well as acknowledging the pressure the provider of services experiences. Often there are not clear indications regarding who is responsible for the decision making and the outcome. This study reaffirms the utility of a human ecological framework in the study of hospital-based discharge planning and case management programs. It acknowledges that discharge planning is dependent at least in part on variables and realities that often are outside the control of any of the participants and, above all, that the process focuses on compromise, negotiation, and positive adjustments. APPENDICES APPENDIX A SURVEY COVER LETTERS, REMINDER LETTERS, AND REMINDER POST CARDS 138 Discharge Planning Survey Cover Letter It currently is not known what types of discharge planning programs have been implemented in acute care hospitals in Michigan. In addition, limited research has been done which focuses on the concerns of clients and families prior to discharge. This survey is designed to identify discharge planning serv- ices that are being provided in Michigan’s acute care hospitals. Acknowledging there is no one common definition or model of discharge planning, survey results will be used to describe programs. The survey also seeks to elicit your percep- tions of the concerns of elderly clients and their families pending discharge. A post card, to be mailed separately from the survey, asks if your hospital provides case management services. All information received will be kept confidential. Survey data will be compiled and published in aggregate only. The survey should be completed by the director of the department who manages the discharge planning/continuing care function. Withdrawal from the survey may occur at any time without consequence. The co-research directors for this study are Dr. Barbara Ames, Associate Professor, Department of Family and Child Ecology, and Dr. Sharon King, Associate Professor, College of Nursing. Thank you in advance for your time and participation. If you have any questions about the survey, please call Ellie Franey at (616) 949-3322. After completing the survey, please staple or tape it closed before mailing. Results of the survey will be available to participating hospitals by returning the enclosed postcard. Ellie Franey, Ph.D. Candidate Department of Family and Child Ecology Michigan State University 139 Case Management Survey Cover Letter It currently is not known what types of case management programs have been implemented in acute care hospitals in Michigan. This survey is designed to identify hospital-based case management services that are being provided in Michigan’s acute care hospitals. Acknowledging there is no one common definition or model of case management, survey results will be used to describe case management programs. The survey should be completed by the person who directs case management. Withdrawal from the survey may occur at any time without consequence. All information received will be kept confidential: Survey data will be compiled and published in aggregate only. The co-research directors for this study are Dr. Barbara Ames, Associate Professor, Department of Family and Child Ecology, and Dr. Sharon King, Associate Professor, College of Nursing. Thank you in advance for your time and participation. If you have any questions about the survey, please call Ellie Franey at (616) 949-3322. After completing the survey, please staple or tape it before mailing. Results of the survey will be available to participating hospitals by returning the enclosed post card. 140 Discharge Planning Survey Reminder Letter Date: Dear Director of Discharge Planning and Continuing Care: Last month you should have received a copy of a survey titled "Discharge Planning." l have not yet received your completed survey. My research is a comprehensive study of discharge planning practices in Michigan hospitals, and your responses are very important. Enclosed is another copy. I’d appreciate it if you could complete all or as much of the survey as possible and return it in the envelope provided. If you do not wish to participate in the study, please indicate this and return the survey. Again, your participation is greatly appreciated. Thank you. Sincerely, Ellie Franey, Ph.D. Candidate 180 Greenwich Rd. NE Grand Rapids, MI 49506 (616) 949-3322 141 Case Management Survey Reminder Letter Date: Dear Director of Case Management: Last month you should have received a copy of a survey titled "Case Management." I have not yet received your completed survey. My research is a comprehensive study of case management practices in Michigan hospitals, and your responses are very important. Enclosed is another copy. I’d appreciate it if you could complete all or as much of the survey as possible and return it in the envelope provided. If you do not wish to participate in the study, please indicate this and return the survey. Again, your participation is greatly appreciated. Thank you. Sincerely, Ellie Franey, Ph.D. Candidate 180 Greenwich Rd. NE Grand Rapids, MI 49506 (616) 949-3322 142 Discharge Planning Survey Reminder Post Card Date, 1994 Dear Director of Discharge Planning and Continuity of Care: Approximately ten days ago you should have received a copy of a survey titled "Discharge Planning." If you have completed and returned the survey, thank you very much. If you have not yet returned the survey, while I know your time is at a premium, I would really appreciate your participation. If you need another copy, please call Ellie Franey at (616) 949-3322 or write me at 180 Greenwich Rd. NE, Grand Rapids, MI 49506. Thank you very much. Ellie Franey 143 Case Management Survey Reminder Post Card Date, 1994 Dear Director of Case Management: Approximately ten days ago you should have received a copy of a survey titled ”Case Management." If you have completed and returned the survey, thank you very much. If you have not yet returned the survey, while I know your time is at a premium, I would really appreciate your participation. If you need another copy, please call Ellie Franey at (616) 949-3322 or write me at 180 Greenwich Rd. NE, Grand Rapids, MI 49506. Thank you very much. Ellie Franey APPENDIX B CASE MANAGEMENT POST CARD 144 Pre-addressed, Stamped Case Management Post Card YES, my hospital does offer case management services. NO, case management is not offered. Thank you. Ellie Franey APPENDIX C SURVEY RESULTS POST CARD 145 Pre-addressed, Stamped Survey Results Post Card YES, I would like to receive the aggregate survey results. Please send to: (Hospital) (Street Address) (City, State, Zip Code) (Attention) APPENDIX D DISCHARGE PLANNING SURVEY 146 DISCHARGE PLANNING SURVEY For the purposes of this survey, a discharge planner is a staff person primarily responsible for discharge planning. What is the name of the department/unit primarily responsible for discharge planning? Discharge planning Continuing care Social services Social work Client services Case management Other (please specify) mme-(JJNH To which hospital department does the discharge planning function report? Nursing Social Work Administration Utilization review Quality assurance ___Other (please specify) UllbbdNH Social Worker Discharge planner Case manager RN Other (please specify) “BOON?“ During 1993, what were your hospital's total number of inpatient acute discharges (medical/surgical, cardiac and critical care)? Approximately what percentage of total annual inpatient discharges were Medicare? % Approximately what percentage of total annual inpatient discharges received the services of a designated discharge 0 planner? a Dis- charge Planner: 2 c 3 U‘ (D H m -—-+——-+—-+——-H——+-—-H—-+——-H—-+-—-H—-+——-H—-+——-H—-+—-+~—~+-—+———— 147 How many persons whose primary responsibility is discharge planning are employed by your hospital? Total number: Number of FTEs: (Please note: 1 FTE = 1 full time equivalent, employed 2,080 hours/year. Use this as a standard to calculate total FTES) Please check the highest educational degree received by each discharge planner. The last page can be used if more space is needed. Educational degree: 01 02 03 04 05 06 07 08 09 MSW Other (specify) DNS/ PhD ---- ---- ---- ---- ---- ---- ---- ---- --------- ——+~—-+—-+-—-H—-+——+-—-H—-+——+~—~H—-+——+——-H—-+——+-—+~—-+—-+ ——+~—-+——+~—-+——+~—-+——-H—-+——-H—-+~—-+——+~—-+——4~—-+——4~—-+—-+- ——-H—~+-—-H—-+——4~—-+——+~—-+——+~—-+——+~—-h—-+——-h—-+——+——-H—-+o ——+~—-+—-+—-H—-+——+~—-+——+~—-+——+~—-+——+_—-h—-+——+_—-H—-+——+- ——-H—-+——-H—-+-—-H—-+——-H——+-—-h——+——-h—-+——+~—-+——+~—~F——+—-+ ——-F—-+-—-H—-+——-H——+——-H——+——-H—-+——-H—-+——-H—-+——-H——+——-H——+ —-+~—-+——+~—-+——+~—-+—-+~—-+——+~—-+——+~—-+——+~—-+——+~—-+——+~—-+ ——4~—-+—-+~—-+——+~—-+——+~—-+——4~—-+——-h—-+——-h—-+-—-H—-+——-H—-+ 10. ll. 12. 148 Are discharge planners designated or assigned, for example, by specialty, floor, or unit? Yes No On average, what percentage of time does a designated discharge planner spend on these functions? Discharge Planning Utilization Review Peer Review Counseling/psychological support Quality improvement activities Meetings/committee work Supervisory activities Other (Please specify) o\° o\° o\° o\° o\° o\° o\° o\° o\° o\° o\° 100% On average, how much orientation to the job did new employees hired as discharge planners receive when they assumed their role in your hospital? None One day 2-7 days 8-14 days 15-21 days 22+ (Please specify # of days) Not applicable On average, how much orientation to the job did continuing employees* hired as discharge planners receive when they assumed their role in your hospital? * Current hospital employees without discharge planning experience who transferred into that position. None One day 2—7 days 8-14 days 15-21 days 22+ (Please specify # of days) Not applicable \ICShLJ'lvbMJKJI-J QCNU'llD-UJNH SIGNUIlh-UJNH Pnl» I e 13. 14. 15. 16. 149 What type of preparation does a new or continuing employee hired as a discharge planner receive? Procedure manual Video Mentoring On-the-job training with an experienced discharge planner Other (please specify) DWNH How (or by whom) are persons identified to receive the services of a discharge planner? Physician referral Nurse referral Social worker screening Members of multidisciplinary teams on rounds High-risk admission screening Utilization review coordinator Community agency referral Other (please specify) \ImUlrbLUNH What criteria are used to determine who is in need of the services of a discharge planner? (Check all those that apply, and circle the one that represents the most frequent indicator.) Age Functional status Social support Diagnosis Other (please specify) thNH On average, for how many beds is a discharge planner responsible? 150 17. On average, what is each discharge planner's daily client case load? 0—15 l6-25 26-30 31-40 41—50 50+ ONUleUJNl-J 18. Approximately what percentage of the daily case load is Medicare clients? % 19. On average, what is the number of closed cases per month per discharge planner? 20. On average, what percentage of a discharge planner's time is spent on the following activities? Coordination of community services Administrative paperwork aspects of discharge Assessment of clients and families Counseling/advising clients and families Other (please specify) lbUONI—t o\° o\o o\° o\° o\° o\° o\° o\° o\° H S Q o\0 21. Does your hospital offer any services which traditionally have been provided in the community? (Check all that apply.) A hospital-based home care program 1 Sale or rental of durable medical equipment 2 A skilled or sub-acute care nursing 3 facility Contracting for nursing home beds 4 Case management services 5 Other (please specify) 151 22. From a discharge planner's perspective, please rate the importance of the following concerns (defined as: fears, worries, and/or anxieties) to elderly cardiovascular clients and their families prior to discharge. Scale of importance: 5 Extremely; 4 = Very; 3 = Moderately; 2 = Slightly; l = Not important. CONCERNS: CLIENT FAMILY Any comments: General medical: pain management, medication side effects, etc. ...................... +__--——-+--___--+----_--—------—--_-----—-- Mechanics of discharge planning/status ————————————————————— +—-——---+---—-—-+-—---_--__--————-_---_---- Amount of time spent with discharge planner ..................... +_---—--+_-_----+----_-—--—---—------_-_—-_ Discharge planning options/destinations --------------------- +-------+___————+-—---——-—-------———-————-- Communication: among clients, families, health care team, MD —————————————————————— +--_----+—-—-—-—+-——_———-—-—----———--—---—- Functional status and prognosis ..................... +-------+-----_-+--_-----_--------------__- Financial/insurance I I I ..................... +---—---+—--—---+-------—-----—-—---------- Psychosocial issues I I I ..................... +_------+--__-_-+-------_-_-------—----_-_- Lifestyle changes: activity/driving e.g. ..................... +--__---+_-_--_-+------------_----_--_-_--- Family role changes/ expectations ..................... +_--_—--+----_--+---_———---—----—_-_-—-——_- Nutritional/diet I I I ..................... +_-----—+_-_----+-------—-----—---------_-- Therapy I I I ..................... +-----—-+---—---+--__-----------_--------_- Family caregiving I I I ..................... +_-—-———+—--———-+_--—----——---—_-—--_—-——_- Home care training I I I ...................... +-------+---_---+-----------------__----_-- l Other (specify) I 23. 24. 25. 26. 152 For those concerns which you rated as "extremely" or "very" important, why, in your opinion, are those concerns so important? Do your routine discharge planning procedures include follow-up services (e.g. phone calls, home visits) for any clients for a limited period of time after discharge?’ Yes 1 No (If no, skip to number 31) 2 If yes, what is the average length of time over which follow-up extends? One day 2—7 days 8—14 days 15-21 days 22+ (Please specify aver. # of days) Not applicable QUllP-UJNH You indicated in #24 that contact is made with some clients following discharge. How are clients selected for follow- up? Random selection from all inpatient clients Random selection of discharge planning clients Non—random selection of all inpatient clients Non-random selection of discharge planning clients Other lbUJNi-J Not applicable 0 27. 28. 29. 30. 153 Who usually makes the follow—up contact? H Discharge planner Administrative/Secretarial staff Non-professional volunteers Other (please specify UJN Not applicable 0 What follow-up methods are used? (Check all that apply.) Mail contact Phone calls Home visits Facility visits Other (specify) DWNH Not applicable 0 For discharge planning clients who received some follow-up contact, approximately what was the percentage breakdown of: (Total may exceed 100%) Mail contact % 1 Phone calls % 2 Home visits % 3 Facility visits % 4 Other (please % specify) % Not applicable 0 What is the primary purpose of client follow-up? Quality assurance 1 To determine the adequacy of the discharge plan 2 To remain in contact with patients who are at 3 high risk for complications and readmission To revise the discharge plan as needed 4 To conduct a patient satisfaction survey ' 5 Other Not applicable 0 31. 32. 33. 34. 35. 36. 154 Do you have a formal mechanism to capture all readmissions previously seen by discharge planners? Yes 1 No 2 If yes, how are you notified? For the purpose of this study case management is defined as a hospital-based service which focuses on ensuring appropriate and continuous care for selected clients after discharge. Does your hospital offer case management services? Yes 1 No 2 If your hospital has not implemented case management, has such a program been considered? Yes 1 No 2 If case management has not been implemented, please indicate the prime reason. Start up costs too high On—going costs estimated to be too high Not a service targeted by administration Community-based case management fulfills the need Other (please specify) shblet-J Regardless of whether your hospital provides case management, based on your experience, what percentage of discharge planning's annual case load needs case management services after discharge? 0 6 155 This space is provided to allow you to ask questions or make comments about this survey, if you wish. You have completed the survey. Your participation is greatly appreciated. Please mail the survey after stapling or taping it closed. A post card is enclosed if you would like to receive the aggregate survey results. To ensure confidentiality please mail the post card separately from the survey. Aqain--much thanks. 156 ADD I TIONAL COMMENTS APPENDIX E CASE MANAGEMENT SURVEY 157 CASE MANAGEMENT SURVEY When were case management services first offered in your hospital? Approximate date: Month Year What is the title of the person completing this survey? Is the case management function: Separate and distinct from hospital 1 discharge planning? Part of Discharge planning? 2 To which department does the case management function report? How many persons primarily responsible for case management are employed by the hospital? Total number: Number of FTEs: (Please note: 1 FTE = 1 Full time employee working 2,080 hours/year. Use that standard to calculate the total FTES). On average, how much orientation to the job did new employees hired as case managers receive? None One day 2-7 days 8-14 days 15-21 days 22 days or more Not applicable ammpwwl—t On average, how much orientation to the job did continuing employees* hired as case managers receive? * Current hospital employees without case management experience who transferred into that position. None One day 2-7 days 8-14 days 15-21 days 22 days or more Not applicable GOUIQUJNH 10. ll. 12. 13. 158 What was the total number of open case management cases during 1993? During 1993, approximately what % of those persons who received case management services were Medicare? % How is case management funded? (Check all the appropriate responses.) Included in the DRG payment from Medicare Included in Medicaid reimbursement Included as an administrative cost Private pay clients Contracts with Medicare or an HMO under a capitated financing program Other, please specify U'IubUJNH Are case management services available to selected clients being discharged: Instead of discharge planning? In addition to discharge planning? How (or by whom) are persons who receive case management services identified? Physician referral Nurses Members of multidisciplinary teams on rounds High-risk screening Social worker screening Discharge planner Community agency referral Utilization review coordinator Other (please specify) What criteria are used to determine who receives case management services? (Check those that apply, and circle the one that represents the most frequent indicator.) Age Functional status Social support Diagnosis Other (please specify) \ImU'I-bU-JNH Dix-INF” 159 Please check the highest educational degree received for each of your case management staff. used if more space is needed. 14. The last page can be Educational degree: 02 03 04 05 06 07 10 01 Dis— charge Other (specify) ————--———-+----+———-+~-—-+——--+-———+--——+—---+—--—+—~-—--—-— DNS/ PhD MSW BSW BA RN BSN RN ADD. RN ILVN Planner: I I I I I I I ___-_-__-_+-__-+-_--+---_+_---+----+---_+----+----+--------- I Number 1 I I I I | | I —-—-—-—--—+-———+—--—+————+—-—-+—---+---—+————+---—+———-————- I Number 2 I I I I I I I ----_---_-+----+-_-_+----+---_+--_-+----+----+----+_------_- I Number 3 I I I I I I I ——---————-+-——-+——--+--—-+—-——+——-—+~——-+~---+-——-+—-—--—-—- Number 4 | I I I I I I _-------_-+-_--+----+-_-_+---—+_--_+----+----+----+--_--_--- Number 5 I I I I I I I —-—-—~—---+----+----+-——-+----+--—-+——--+----+—-—-+—-—---—-— Number 6 I I I I I I I -—-------—+-———+——--+----+———-+————+--——+————+——--+——-————-— Number 7 I I I I I I I ----——---—+—-—-+---—+—---+-—--+-——-+--——+-—-—+———-+---————-- Number 8 I I I I I I I ———-—————-+-—~—+-—-—+----+-———+—-—-+———-+--—-+————+-——-——-—- Number 9 ----——-———+-——-+---—+-——-+-——-I———-+---—+--——I———-I-——--_--- Number 10 I I I I I I I I ----—--—--+----+————+--—-+—-——+-—-—+-—--+—---+--——+--—---—-— Number 11 I I I I I I I I -----—-——-+-———+----+-———+—-——+——--+---—+————+--——+-——-—_--- Number 12 I I I I I I I ----—-——--+----+—---+----+—-—-+-—-—+—--—+--—-+-—--+—-——_—_-- Number 13 I I I I I I I ——-—-——--—+---—+——-—+-—--+--—-+-—-—+--—-+-—--+-—--+-——————_- Number 14 I I | I I I I ---——--—--+---—+—---+——-—+——--+——--+---—+-———+———-+---—----- Number 15 I I I I I I I I ---——-——--+—--—+—--—+---—+—---+----+-—--+-—--+-—-—+---—-——-- I Number 16 I I I I I I I --—-----—-+—-—-+-—-—+---—+—--—+——-—+—-——+-——-+----+-——-—---_ Number 17 I I I I I I I -—--————-—+-_--+---—+—-—-+-——-+--_-+-__-+---—+——--+---7----- Number 18 I 160 15. On average, what percentage of a case manager's time is spent performing the following activities? Coordination of community services Administration/paperwork Assessment of clients and families Counselling/advising clients and families Other (please specify) bbJNI-J o\° o\° o\° o\° o\° o\° o\° o\° 100% 16. On average, approximately what is a case manager's monthly case load? clients. 17. On average, how often is each case managed client contacted? times per . 18. What contact methods are used? (Check all that apply.) Phone calls Home visits Facility visits 3 Other, please specify NH 19. In a given month, approximately what percentage of clients are contacted by the following means? (Total may exceed 100%) Phone calls Home visits Facility visits 3 Other (please specify) NIP-t o\° o\° o\° o\° o\° o\° 161 20. Why was case management implemented in your hospital? (Check all that apply.) Community—based case management was not adequate Hospital strategy is to expand service base Large target population exists. Concern for client length of stay and resulting expense to hospital Issues of quality client care As an attempt to reduce readmissions rates Other (please specify) 21. What information is collected on case managed clients? (Check all that apply.) Length of hospital stay Services provided by the case manager Length of time as an active CM client Hospital readmissions Client outcome Cost of case manager services Other, please specify 22. Are you measuring the costs of the case management program? Yes No If yes, please describe what costs you measure: WNH munc- mU'IrbUJNH 24. 25. 26. 27. 162 Is it considered cost effective for your hospital to offer case management services? Yes 1 No 2 If yes, please explain: Have you been measuring any quality outcomes? Yes 1 No (If no, skip to # 26) 2 If yes, please describe what quality outcomes you are measuring. If yes to #24, what criteria do you use to measure quality outcomes for case managed clients? Have any internal studies of the case management program been done? Yes 1 No 2 If yes, describe Has the average length of stay changed since case management was implemented? H Yes No 2 If yes, describe the change 28. 2Q. 30. 31. 163 Have you made any modifications in the case management program since it was started? Yes 1 No 2 If yes, please describe what changes have been made and why? Do you monitor readmissions for case managed clients? Yes 1 No (If no, skip to #31) 2 Has the readmission rate changed since the hospital initiated case management? Yes 1 No 2 If yes, please describe the change: What do you perceive are the benefits of your case management program--particularly for elderly clients and their families? 164 This space is provided to allow you to ask questions or make comments about this survey, if you wish. You have completed the survey. Thank you very much for your participation. Please staple or tape the survey before mailing it. A postcard is enclosed if you would like to receive the aggregate survey results. To ensure confidentiality please mail the post card separately from the survey. Again, much thanks for your help. 165 ADDITIONAL COMMENTS APPENDIX F GLOSSARY 166 Glossary AgilitiesbfdailxliiinglADle: A functional assessment that refers to bathing, dressing, eating, toileting, continence, transferring, and ambulation. Cardjgyasgular: Pertaining to the heart and blood vessels. ("Cardio" means heart; "vascular" means blood vessels.) The circulatory system of the heart and blood vessels is the cardiovascular system. The major cardiovascular diseases are ischemic (coronary) disease, hypertensive disease, rheumatic fever/ rheumatic heart disease, and cerebrovascular disease (stroke) (American Heart Association, 1994). WWW: Classification system that groups patients into categories based on diagnosis, age, treatment, surgery, complications, length of stay, and other diseases. thEAltlealthLariEfllamiluAdministratiin: Agency within the Department of Health and Human Services (DHHS) that governs the disbursement of Medicare as well as other publicly funded programs. WW5): Functional assessment that refers to shopping, using the telephone, mobility to go out of doors, and so on. Medjgare: Title XVII (Public Law 87-97), Health Insurance for the Aged, Amendment to the Social Security Act of 1965. Provides a program of medical care for persons age 65 and over and selected persons under 65. Includes insurance protection for hospitalization and physician’s care and other health services. There are some limited provisions for home care. 167 Medjgajd: Title XIX (Public Law 87-97), Medical Assistance, Amendment to the Social Security Act of 1965. Provides a program of care for public aid recipients and people whose incomes exceed public aid limits but who meet other criteria and cannot pay for medical services. WW: TEFRA legislation repealed PSROs and substituted PSOs. The Department of Health and Human Services (DHHS) enters into agreements with PROs to perform utilization review and quality control over peer review. PROs are centralized at the state level; review is external to the hOSpital and includes the authority to deny Medicare payment. The major difference between PSROs and PROs is that a PRO emphasizes quality-of-care issues over cost-control issues. The impetus for this shift in focus was the implementation of PPS for hospital reimbursement. EmtessimaLstammMmzaflmflESBQs) Responsible for ensuring that federally reimbursed health services are medically necessary, meet recognized standards of care, and are provided in the most economical setting. WM: System in which the method of payment by third-party payers is based on DRGs and not on actual costs. As of October 1, 1983, prospective payment for recipients of Medicare was in effect. IEEBA: Tax Equity and Fiscal Responsibility Act of 1982 (Public Law 97- 248). Laid the groundwork for PPS, which was operationalized for Medicare recipients on October 1, 1983. LIST OF REFERENCES LIST OF REFERENCES Abramson, J., Donnelly,J., King, M., 8Malick, M. (1993). Disagreementsin discharge planning: Anormative phenomenon. [155mm IALOLIS 18. 57- 63. Albert, S. M. (1990). Caregiving as a cultural system. Conceptions of filial obligation and parental dependency ln urban America. American ADIDLQDQIQQISL 92, 319- 331. American Association forContinuity of Care. (1993, November). Ami-55. Arlington, VA: Author. American Health Planning Association. (1992). Agnidejgflannmlgngfierm carellealtnsenricesfortbeeldsnx. Washington, DC: Author. American Heart Association. (1994). Wm supplement. Dallas, TX: Author. AmencanfientagejlctlonanrofjbeEngllananguage. (1969). New York: American Heritage Publishing Co. American Hospital Association. (1984). Wining. Chicago: Author. American HospitalAssociation. (1994a). InsAmsnsanflanltaLAssoclatlon guideJthenealtnsarejeld. Chicago: Author. American Hospital Association. (1994b). HQSQIIaLSIatlstlgsJSQl-Qiemtm Chicago: Author. Anders, G. (1994, January 31). Boom in health—care consulting sours mergers. IbelALallStreetJnurnal. pp. Bl. 86. Archbold, P. G. (1982). All-consuming activity: The family as caregiver. Generations 501), 12-13, 40. 168 169 Arenth, L. M., 8 Mamon, J. A. (1985). Determining patient needs after discharge. NurslnoManagement. 16(9). 20-24. Beach, D. L. (1993). Gerontological caregiving: Analysis of family experience. JournalotGeLontolooieaLNursing. 19(12), 3541. Beck, J. (1987). Hospital responsibilities in developing systems of care of the elderly: Partl.Annals_Boxal_Colleoe_of_El11solans_and_Sumeons_of Canada. 20, 353- 356. Bengston, V. L. (1979). You and your aging parent: Research perspective on intergenerational interaction. In P. Ragan (Ed.), Agingparents (pp. 41- 68). Los Angeles: University of Southern California Press. Berkman, B. (1989). Quality assurance, utilization review, and discharge planning. In P. Volland (Ed.).Dlsebarge_olannlno_An1nterdlsopllnanr approaonjoeontinuitufearemp. 255-277). Owings Mills, MD: National Health Publishing. Blumenfield, S. (1986). Editorial: Discharge planning: Changes for hospital social work' In a new health care climate. QuafitLReyiewBuuetin, 12(2), 51 54. Blumenfield, S., 8 Rosenberg, G. (1988). Towards a network of social health services: Redefining discharge planning and expanding the social work domain. SoQIaUNQLKJaneaIthCaLe.13(4).31-48 Brody, E. M. (1985). Parent care as a normative family stress. GerontgLogjsj, 25, 19-29. Brody, E. M., Kleban, M. H., Johnsen, P. T., Hoffman, C., 8 Schoonover, C. B. (1987). Work status and parent care: A comparison of four groups of women. 9531019103315], 21, 201 -208. Brody, E. M., Litvin, S. J., Albert, S. M., 8 Hoffman, C. J. (1994). Marital status of daughters and patterns of parent care. Journalgoj Gerontology. 49, 895-8103. Brody, S., 8Persily, N. (1984). HosMabeMJbeagedeeneMdmamm. Rockville, MD: Aspen. Bronfenbrenner, U. (1979). IhflsCIQQLQLhumamdeMelonennjxoeri: ments_by_nature_and_desion. Cambridge, MA. Harvard University Press. 170 Bubolz, M. M., Eicher, J. B., 8 Sontag, M. S. (1979, Spring). The human ecosystem: A model. JournalottlomeEconomlos. 11(1). 28-31. Bubolz, M. M. 8Sontag, M. S. (1993). Human ecology theory In P. Boss, W. Doherty, R. LaRossa, W. Schumm, 8S. Steinmetz (Eds) o ‘00-. 0 all I or 10 II no ’ a 01:4... to 0. I (pp. 419-448). New York: Plenum. Bull, M. J. (1988). Influence of diagnostic-related groups on discharge planning, professional practice and patient care. JoumaLoj Emfesslonalflurslng. 4.. 415-421. Cannon, I. M. (1913). Socralnuominnosoitals. New York: Russell Sage Foundafion. Cantor, M. H. (1983). Strain among caregivers: A study of experience in the United States. GeLQntQIQgist. 23. 597-604. Cicirelli, V. G. (1988). A measure of filial anxiety regarding anticipated care of elderly parents. Gerontologisj, 28, 478-483. Cicirelli, V. G. (1990). Family support in relation to the health problems of the elderly. lnT. H. Brubaker (Ed.) Eamily.relationshiosin.later.liie(pp 212-228). Newbury Park, CA: Sage Cicirelli, V. G. (1991). Sibling relationships in adulthood (Families: lntergenerational and generational connections, part 2). MW Eamily.Be1iew.J_6 291-311. congaminev L- L- 0935)- Eamlltroaradiomsilneoracticemmeontintamfly therapy. New York: Guilford. Coulton, C. J. (1988). Prospective payment requires increased attention to quality of post hospital care. SociaIJnLorkJnilealtoCare. 13(4). 19-29. Coulton, C. J., Dunkle, R. E., Roode, R. A. 8Maclntosh, J. (1982). Discharge planning and decision making. HeathendfiooiaLflork. Z. 253-261. Creasey, G. L., Myers, B. J, Epperson, M. J, 8Taylor, J. (1990). Couples with an elderly parent with Alzheimer’s disease: Perceptions of familial relationship. BsychiathnemersonaLandflolooicaLELocesses. 53(1) 44-52. 171 Crittenden, F. J. (1983). DisobargeolanningioLnealtneareJaollities. Los Angeles: University of California Extension Allied Health Publications. Crossman, L., London, C., 8 Barry, C. (1981). Older women caring for disabled spouses: A model for supportive services. Gerontologist, 21, 464-470. Davis, L. (1960). EellowsbrpotsurgeonsflrstonroftbeAmenoanCoflege QLSULgeQns. Chicago: Charles C. Thomas. Dawson, D., Hendershot, G., 8 Fulton, J. (1987, June 10). Aging in the eighties: Functional limitations of individuals age 65 and over. Adyance Data no. 133 (National Center for Health Statistics). Decker, C. M. (1985). Quality assurance: Accent on monitoring. Nursing Management 16(11). 20-22. Dinerman, M. Seaton, R, 8Schlesinger, E. G. (1987). Surviving DRGS: New Jersey” 3 social work experience with prospective payments. SocialJALorkJotleaItCCaLe.12(1),103-113. Donabedian, A. (1969). Quality of care: Problems of measurement. Part 2: Some issues of evaluating the quality of nursing care. Amerigan loumaloLEubljotlealtb. 59. 1833-1836. Donabedian, A. (1976). BenefitsjomedioaLcareorograms. Cambridge, MA: Harvard University Press. Donabedian, A. (1980). Exoloratronsnngualltussessmentenomonrtonng. Oll‘ I‘O‘IOIOOq -.l0 2-000 I‘ ll‘l Ann Arbor, MI: Health Administration Press. Donabedian, A. (1987). Commentary on some studies of the quality of care. tlealtbCareErnanorngBemee, Annual SUpplement Ethridge, P., 8 Lamb, G. S. (1989). Professional nursing case management improves quality, access, and costs. NursingManagement 20(3), 30- 35. Fink, A., Siu, A. L. Brook, R. H., Park, R. E, 8Solomon, D. H. (1987). Assuring the quality of health care for older persons. An expert panel’ 3 priorities. JournaLofJneAmerioanMegioalAssociation 258(14).1905- 1908. 172 Fischer, L. R., 8 Eustis, N. N. (1988). DRGs and family care for the elderly: A case study. Gerontologist. 28. 383-389. Franks, M. M., 8 Stephens, M. A. (1992). Multiple roles of middle-generation caregivers: Contextual effects and psychological mechanisms. Jamaaj5 oLGerontology. 42. $123-$129. Fromberg, R. (Ed.). (1986). Monitoringanoeualuationrnnursingsenrioes. Chicago: Joint Commission on Accreditation of Hospitals. Gehl, M. B., 8Lantzy,A. (1990). Parents’ needs surrounding discharge from the neonatal intensive care unit (NICU). Matemalfimltlflursmg Journal. 19(2). 179 181 Germain, C. B. (1990). An ecological perspective on social work practice in health care. In K. Davidson 88. Clarke (Eds). Sociamorkjnhealth oareonhandoookjororaotloenflanump. 51-62). New York: Haworth. Glennon, T. P. 8 Smith, B. S. (1990). Questions asked by patients and their support groups during family conferences on inpatient rehabilitation units.ALthues_Qf_EI1¥staLMeoiCaLBehabiIitation.LL 699-702. Go'ant’ 8' (1984)' WWW—835mm age. New York: Columbia University Press. Graham, N. (1987). A quality of care assessment: Pediatricians and pediatric nurse practitioners. Image. 10(2), 41-48. Grau, L. (1984). Case management and the nurse. GeriatriCNursing. 5. 372- 375. Guterman, S. 8Dobson, A. (1986). Impact of the Medicare prospective payment system for hospitals. W16), 97- 1 14. Hagestad, G. O. (1986). The aging society as a context for family life. Daedalus. 155. 119-139. Hartigan, E. G. 8 Brown, D. J. (1985a). Definitions, goals, benefits, and principles. In E. G. Hartigan 8 D. J. Brown (Eds.,) Disehargeolanning tQLcontlnulttLoLQaremp 9- 1.4) New York: National League for Nursing. 173 Hartigan, E. G., 8 Brown, D. J. (1985b). Finance and regulations. In E. G. Hartigan 8 D. J. Brown (Eds). Dischargeolanningioreontinuitufoare (pp. 15- -1.8) New York: National League for Nursing. Hartigan, E. G., 8Brown, D. J. (1985c). The service population. In E. G. Hartigan 8 D. J. Brown (Eds) Dischargeoanningforoontinuinrotoare (pp. 19-28). New York: National League for Nursing. Hogan, D. B., 8 Fox, R. S. (1990). A prospective controlled trial of a geriatric consultation team in an acute care hospital. AgeansLAgeing, 19, 107- 1 13. Hurley,R. E. (1993). Manageoeare_In_Meoloaioz_Lessonsfor_oolioy_ano W. Ann Arbor, MI: Health Administration Press. lglehart, A. (1990). Discharge planning: Professional perspectives versus organizational effects. lzlealtnanoSoolaLlALork. 15, 301 3-09. James, C. S. (1987). An ecological approach to defining discharge planning in social work SooiaLWorkjnfiealtnCare.12(4). 47-59. Jennings, B. M, 8Meleis, A. I. (1988). Nursrng theory and administrative practice. Agenda for the 1990s. Aduanoeslnflurslngficlenoe 10(3), 56- 69. Johnson, C., 8 Catalano, D. J. (1983). A longitudinal study of family supports to impaired elderly. Gamntologjst, 23, 612-618. Johnson, C. L., 8 Troll, L. (1992, March). Family functioning in later life. JournalsoLGerontology. 5L7. $66-$67. Johnson, M, 8 Fethke, C. (1985). Post-discharge outcomes and care planning for the hospitalized elderly. In E. McClelland, K. Kelly, 8 K. Buckwalter (Eds) Continuity_of_oare:_Aduanoing_tne_concept_of Margaulannjng (pp. 229-240). New York: Grune 8 Stratton. 0'1 011113101; "H.010 .0 0'. AI' 11.1 -. 00:11-1. (1975). Oakbrook Terrace, IL: JCAH. I O. . O O O O ‘ . 01 01111 0101- ‘0.010-'-_1-.‘01-.1.01 .110 Standardimanual. (1994). Oakbrook Terrace, IL: JCAHO. 174 Kahana, E. (1982). A congruence model of person-environment interaction. In M. P. Lawton, P. Windley, 8 T. Byers (Eds). Agjngandjha emrironment (pp. 97-121). New York: Springer. Kahn, K. L., Rubenstein, L. V., Draper, D., Kosecoff, J., Rogers, W. H., Keeler, E. B.. 8 Brook, R. H. (1990). The effects of the DRG-based prospective payment system on quality of care for hOSpitalized Medicare patients. JoumaLetheAmerieanMedloaLAssociation. 264. 1953- 1955. Kane, R. A. (1985). Case management in health care settings. In M. Weil, J. M. Karls, 8Associates (Eds). Casemanagementjnjumanjenrice oracliee (pp. 170-203). San Francisco: Jossey-Bass. Kane, R. L.. Ouslander, J. G.. 8 Abrass, l. B. (1984). W genomes. New York: McGraw-Hill. Kantor. D-v ail-9hr. W- (1975). lnsrdereIamfluioinarojtneonrottamlly orooess. New York: Harper 8 Row. Kosecoff, J., Kahn, K. L.. Rogers, W. H., Reinisch, E. J., Sherwood, M. J., Rubenstein, L. V, Draper, D, Roth. C. P.. Chew, C. 8 Brook, R. H. (1990). Prospective payment system and impairment at discharge. The "quicker-and—sicker" story revisited. JournamflneAmerioan MedioalAssooiation.2%.1980-1983 Kruse, K. A. (1985). Analysis of roles in discharge planning. In E. McClelland, K. Kelly, 8 K. C. Buckwalter (Eds) Continuinrotoara; Adranolngtneoonoeotmoisonargeolanning (pp. 67-78). New York: Grune 8 Stratton. Langlie, J. K. (1977). Social network, health beliefs, and preventative health behavior. JournaloflzlealtnanofiooiaLBenauior 18. 244-260. Larson, E. L.. 8 Peters. D. A. (1986). Integrating cost analysrs in quality assurance. JournanLNurslngCuaIIMAssuranoela). 1-7. Lee. G. R. (1988). Aging and intergenerational relations. Joumaljfliamjjy Issues. 8. 448-450. Lehman. R. D. (1987). Q. A. update. Quality_Be1iew_B.uIIetin.16(4). 148-150. 175 Longino, C. (1990). Geographical mobility and family caregiving in nonmetropolitan America: Three-decade evidence from the US. Census. EamihrBelations. 39(1), 38-44. Loveridge, C. E.. Cummings. S. H., 80’M.alley,J (1988). Developing case management in a primary nursing system. JeurnaLeLNursing Administration. 18(10), 36-39. MacAdam. M.. Capitman, J., Yee, D., Prottas, J., Leutz, W.. 8 Westwater, D. (1989). Case management for frail elders: The Robert Wood Johnson Foundation’s program for hospital initiatives in long-term care. Gemmelegist. 29. 737-744. Markson, E. W. (1992). Physiological changes, illness, and health care use in later life. In B. B. Hess 8 E. W. Markson (Eds). Wm (pp. 173-186). New Brunswick, NJ: Transaction. Martin, L. (1989). Caaemanagament. Arcadia. CA: Medical Management Development Associates. McCubbin. H. I., 8Patterson, J. M. (1982). Family adaptation to crises. In H. M. McCubbin. A. E. Cauble, 8J. M. Patterson (Eds.,) Eamjly_stres5. oooingandsooiaLsuoooerp 2647) Springfield “-1 Thomas McKeehan, K. (Ed). (1981). WWW dischargeolanning. St. Louis: C. V. Mosby. McNamara. E. (1985). Patient and family Involvement In E. Hartigan 8 D. J. Brown (Eds.,) Disobergeolannlngioncontinuilxotcarflpp 29-34) New York: National League for Nursing. Medicare and Medicaid. (1989, June 13). Medioareorosoeotlireoaymentand tneAmenoanmealtnsaresystemmntoCongressmo. 588). Chicago. Congress Clearing House. Meyer. J. A. (1993). Managedmomoetrtronunhealttroawnltdnork? Reston, VA: Economic 8 Social Research Institute. Michigan HospitalAssociation. (1993). Eactsaboutnospitamahaalmgam inMobiganJSde-Jeel Lansing: Author Michigan Hospital Association. (1994). MembershitLdireotonr Lansing: Author. 176 Montgomery. R., 8 Borgatta, E. (1989). The effects of alternative support strategies on family caregiving. Gerontologist, 29. 457-464. Morrow-Howell, N., Proctor. E. K., 8 Mui, A. C. (1991). Adequacy of discharge planning for elderly patients. mm mm: 21(1): 6'12. Morse. J. 8Johnson. J. (1991). Understandan the illness experience. In J. M. Morse etal. (Eds.,) Inejllnessexoerienoe:_Dimensions_of.suflering (pp. 4-5). London: Sage. Moss, M. 8.. Moss, S. 2.. 8Mole. E. L. (1985). The quality of relationships between elderly parents and their out-of-town children. Gerontologjst, 26. 134- 140. Murray. 8. K.. Garraway, W. M.. Akhtar, A. J., 8 Prescott. R. J. (1982). Communication between home and hospital in the management of acute stroke in the elderly: Results from a controlled trial. Health Bulletin, 49, 214-219. Noelker. L. 8.. 8Wallace. R. W. (1985). The organization of family care for impaired elderly. JoumalmEamiILIssues. 6. 2344 Office of National Costs Estimates. (1990). National health expenditures, 1988. tleaunCaeEinanoinoBeuiew.11(4).1-41. Office of the State Registrar and Center for Health Statistics. (1993). Adyanee ._‘ -_.‘I00l§I I- 'HOSOO‘UOIIO-HI"I Lansing. Michigan Department of Public Health (MDPH). O’l-lare, P. 8Terry,M. (1988). Disonameolanningesuateglesjorassuring centinuityeLcare. Rockville, MD: Aspen. Oktay, J. S.. Steinwachs, D. M. Mamon, J., Bone. L. R., 8Fahey. M. (1992). Evaluating social work, discharge planning services for elderly people: Access, complexity and outcome. Heaflbendfiecraflflork. 11. 290- 298. Olsen, J., 8 Lyon. J. C. (1989). Nursing staff determination: A merging of ethics standards. quality, and costs. In T. Moore 8 E. Simindinger (Eds), Managingjhenursingehofiage (pp. 133-149). Rockville, MD: Aspen. 177 QnmibusBeoeneiliatienAet. (1981). PL 7970-35. Washington, DC: US. Government Printing Office. Proctor. E., Morrow-Howell. N., Albaz, R., 8 Weir, C. (1992). Patient and family satisfaction with discharge plans. MedjeaLCare, 30, 262-275. Quinn. J. (1992). WWW experience. New York: Springer. Rehr. H. (1986). Discharge planning: An ongoing function of quality care. Cuality.BeuiemBulletln.12(2). 47-50. Rhoads. C.. Dean. J., Cason, C., 8 Blaylock. A. (1992). Comprehensive discharge planning. Hometlealtheareuurse. 10(6), 13-18. Rogers, D., 8 Stout. H. (1994. September 30). Health reform is dead for ’94, Mitchell admits. Ibeflaflflreetueumal. p. 2. Rorden, J. W., 8Taft, E. (1990). Dischargeolanningguide. Philadelphia: Harcourt Brace Jovanovich. Rosen, S. (1985). Diversification sparks concern over continuity of care. tICSQIlaIS. 59. 92-96. Rossen. S.. 8Coulton. C. (1985). Research agenda for discharge planning. SocialYllorkJnfiealtbCare. 16(4). 55-61 Rossman. l. (1977). Options for care of the aged sick. HoseitaLEraotioe.12. 107-1 16. Rowland. H. S.. 8 Rowland. B. L. (1989). InemanuaLoLnursingguality assurance. Rockville, MD: Aspen. Schrager, J., Halman. M., Myers, D.. Nichols, R.. 8Rosenblum. L. (1978). lmpediments to the course and effectiveness of discharge planning. SooiaLlAlorItjnhealthCare. 4(1), 65-79. Secord. L. J. (1987). Enuateeasemanagementjorolderoersonsandjnerr WW. Excelsior, MN. Interstudy. Center for Aging and Long-Term Care. Shanas, E. (1979). Social myth as hypothesis: The case of family relations of old people. Gerontologist. 19. 3-9. 178 Simmons, W. J., 8White. M. (1988). Case management and discharge planning. Two dlfferent worlds In P. Volland (Ed..) (pp. 217-238). Owings Mills. MD: National Health Publishing. Society for Hospital Social Work Directors. (1984). Disebargeolanning update. Chicago: American Hospital Association. Steinberg. R. M., 8 Carter. G. W. (1983). Casemanagementanojbeeloerlx. Lexington. MA: Lexington Books. D. C. Heath. Stetler. C. (1988). goalsotcasemanagementandmanagedmre. Boston: New England Medical Center. Stoller, E. P., 8 Pugliesi, K. L. (1989). Other roles of caregivers: Competing responsibilities or supportive resources. JeumaILQLGerQntology. 4.4. $231-$238. Stone, R.. Cafferata, G.. 8 Sangl, J. (1987). Caregivers of the frail elderly: A national profile. Gerontologi51. 21. 616-626. Tierney. A.. Closs, 8., Hunter, H., 8Macmillan, M. (1993). Experiences of elderly patients concerning discharge from the hospital. Joumalgj CIinioaLNurslng. 2 179- 185. Tubman, J. (1986. November). Eamrly_relations_ln.oarent_care._Moving herondlneonmaryoaregnrer. Paper presented at the annual National Council on Family Relations Theory Construction and Research Methodology Workshop, Dearborn, MI. Tuzman, L.. 8Cohen, A. (1992). Clinicaldecision making for discharge planning in a changing psychiatric environment. Healtnandfioelal Work. 11. 299- 306. US. Department of Commerce/lntemational Trade Administration. (1990). Health and medical services. U.§._indu51rial_o_utlook. Washington. DC: US. Government Printing Office. Volland, P. J. (1989). Evolution of discharge planning. In P. Volland (Ed ), l' 1.0‘0 11'10 .‘.1"1‘o ”.011 no 1 o 01"1110 (pp. 1- -1.8) Owings Mills. MD: National Health Publishing. Ward, R. A.. La Gory. M.. 8 Sherman. S. (1988). Ibeenirironmenlferaging Tuscaloosa: University of Alabama Press. 179 Waters, K. R. (1987). Discharge planning: An exploratory study of the process of discharge planning on geriatric wards. JournaLQLAdyanged Nursing. 12. 71-83. Weil. M.. Karls, J. M.. 8Associates. (1985). Casemanagementjnnuman senrioenraotioe. San Francisco. Jossey-Bass. Westney. O. E. (1993). Human ecology theory Implications for education. research. and practice. In P. Boss. W. Doherty, R. LaRossa, W. Schumm, 8S. Steinmetz (Eds). Souroebookotfamilydneonesand methoos._A_contextuaLaooroaon(pp 448-450) New York: Plenum. What’s happening with health care reform? (1994. Summer). BespiteBepon. pp. 1. 2. Whitbeck. L.. Hoyt, D. R.. 8 Huck, S. M. (1994). Early family relationships. intergenerational solidarity. and support provided to parents by their adult children. JournaIsQLGeLQntology. 4.9. 885-894. White. M. (1988, January-February). Disehargeolanningmate. Chicago: American Hospital Association. Wright. S. D., 8 Herrin, D. A. (1988). Ecology. human ecology. and the study ofthe family: Part2. EamlllrSoienceBeiriew. 1. 253-282. Zander. K. S. (1988). Nursing case management: Strategic management of cost and quality outcomes. JoumaloLNursingAdministration. 18(5). 23-30. Zarit, s. H., Orr, N. K.. 8Zarit. J. M. (1985). IbehiddenuiotlmsotAlzbeimefis disease:_EamilieS_undeLstLess. New York: New York University Press. Zarit, S. H., Todd, P. A.. 8 Zarit, J. M. (1986). Subjective burden of husbands and wives as caregivers: A longitudinal study. Gerontologst 26. 260- 266. Zarle, N. (1987). ConthngoareLJneorocessandoraotioeotdisonarge planning. Rockville, MD: Aspen. BIBLIOGRAPHY BIBLIOGRAPHY Bair, N. L., Griswold, J., 8 Head, J. (1989). Clinical RN involvement in bedside-centered case management. NursjneEconomjes 2(3). 150- 154. Bejciy-Spring. S. (1991). Nursing case management. Appllcatlon to neuroscience nursing. Jeumamtfleumsgeneefiumng, 23. 390- 397. Bengston, V. L., 8 Kuypers. J. (1986). The family support cycle. Psychosocial issues in the aging family. InJ. Munnichs, P. Mussen. 8 E. Olbrich (Eds) Lifespanandenangeunegerontologloaloersoeotne. Orlando. FL: Academic Press. Blaylock. A.. 8Cason. C. (1992). Discharge planning: Predicting patients’ needs. JoumaLofGerontologloaLNursing. 18(7). 3- 10. Bowers, B. (1987). lntergenerational caregiving: Adult caregivers and their aging parents. Aduaneeeflursingfieienoe. 9. 20-31. Cabot. R. (1919). SoolaLworkessaxsoanemeennogrounomiooctoLand seeialauorker. New York. Houghton- -Mifflin. Charmaz, K- “991)— Gooouaysroaouaysrlbeselfumnromoiflnessano time. New Brunswick. NJ: Rutgers University. Christianson, J. (1991, Summer). Hospital case management: Bridging acute and long-term care. HealtnAflairs. 1_Q, 173-184. Coe, M.. Wilkinson. A.. 8 Patterson, P. (1986). W. Beaverton: Northwest Oregon Health Systems. Coulton, C. (1988). Prospective payment requires increased attention to quality post-hospitalcare. SoclaunrorkjnfiealtnCare.13(4).19-30. Coulton, C.. Dunkle, R.. 8 Chow. J. (1988). Dimensions of post-hospital care decision making: A factor analytic study. Gerontologist. 28, 218-222. 180 181 Dugan, J., 8Mosel. L. (1992). Patients in acute care settings. Which health- care services are provided? Joumalfifiernntelogrealflrslng. 18(7). 31-36. Fethke, C.. 8 Johnson, N. (1986). Risk factors affecting readmissions of the elderly into the health care system. MedjeaLQare, 24, 429. Glenn, M. (1987). Structurally determined conflicts in health care. Eamjly SystemsMedioine. 5. 413-427. Gross, K. (1986). A quality and cost control model for managing nursing utilization. JoumaloLNursingCualitrAssuranoe. 1(1). 3646. Hagestad, G. (1988). Demographic change and the life course: Some emerging trends in the family realm. Eamflyfielatjene, 31, 405-414. Hamilton. 8.. 8 Vessey, J. (1991). Pediatric discharge planning. Eedjatrie Nursing. 1.8. 475-478. Horowitz, A.. 8Dobrof, R. (1982). IneroleotfamlllesunmoindingJongJerm 1.... '10101..""1011 011111'\. New York: Hunter College. Brookdale Center on Aging. Jones. E.. Densen. P.. 8Brown, S. (1989). Posthospital needs of elderly people at home: Findings from an eight-month follow-up study. Health SenrioesBesearcn. 24, 645-664. Kane. R. L.. Matthias. R.. 8 Sampson, S. (1983). The risk of placement in a nursing home after acute hospitalization. MajjeaLCare, 21. 1055-1061. King. C., 8 Macmillan. M. (1994). Documentation and discharge planning for elderly patients. Nursinglimee. 90(20). 31-33. Mullahy, C. (1990). Empowering the case manager. Continumgfiare, 9(7). 15-16, 18-20. 30. Naylor, M. (1990). Comprehensive discharge planning for hospitalized elderly: A pilot study. NursinoBesearcn 39(3). 156-161. Neidlinger. 8., Scroggins. K., 8 Kennedy, L. (1987). Cost evaluation of discharge planning for hospitalized elderly. MW, 5, 225- 230. 182 Netting, F. E.. Williams. F.. Jones-McClintic, S., 8 Warrick. L. (1990). Policies to enhance coordination in hospital-based case management programs. Healthandfiociamlork. 16. 15-21. Newcomer, R.. Wood, J., 8 Sankar. A. (1985). Medicare prospective payment: Anticipated effect on hospitals, other community agencies, and families. JoumaLoLHealtnEolltloLEolioLaniLaw. 1.0. 275-282 Office of Health Coalitions and Private Sector Initiatives, American Hospital Association. (1992). Digestetbealtnmreuseanoexoenseindioators. Chicago: American Hospital Association. Reamer, F. (1985). Facing up to the challenge of DRGs. Healthandfioc’ral Work. 1.0. 85-94. Rogers. W.. Draper. D.. 8Kahn, K. (1990). Quality of care before and after implementation of the DRG-based prospective payment system: A summary of effects. JoumaLofJneAmerioanMedioaLAssociatlon. 2%. 1989- 1994. Schwartz. P.. Blumenfield. S., 8 Perleman-Simon, E. (1990). The interim homecare program: An innovative discharge planning alternative. Healtnanofiooiaunrork. 1.5. 152-159. Sharpe, L. (1991, July-August). Discharge planning before the fact. DischargeElanninollpdate. pp. 3-4. Sizemore, M., Bennett. R.. 8Anderson. R. (1989). Public hospital-based geriatric case management. JournaIQLGerontologleaLSoelallNork. 1.3. 167-179. Special Committee on Aging. United States Senate. (1985. September 26). 110.01 0 11:.0'.. ' o o 1‘01 ‘ 0.111 ‘11011‘ 0-1 o reoeluedbLMeoioaenenefloanes. Washington. DC: US. Government Printing Office. Staff. (1986). Postacute care gaps: Fueling discharge debate? Hospitals, 60(5). 88-89. Stephens. M.. Norris, V., Kinney. J., Ritchie, S., 8 Grotz, R. (1988). Stressful situations in caregiving relations between caregiving coping and well- being. EsydndldgirandAging. 3. 208-209. 183 Victor. C. R. (1991). Healthanonealtncareanatelite. London: Open University Press. Weinberger. M., Smith. D., Katz. 3.. 8 Moore. P. (1988). The cost- effectiveness of intensive postdischarge care: A randomized trial. MedioaLCare. 26. 1092-1101. Wilson, E., Deeves, M. E., Clancy. C., 8Schmitt. A. (1991). Takeafresh look at discharge planning. GeriatfieNuLsing, 12, 23-25. Wimberley, E., 8 Blazyk, S. (1989). Monitoring patient outcome following discharge: A computerized geriatric case-management system. Health andSooiaUNork. 14 269-276.