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The purpose of this paper is to investigate how three communication interventions commonly used during discharge planning and care transitions enable inter-professional knowledge sharing and learning as a foundation for more integrated working. These interventions include information communication systems, dedicated discharge planning roles and group-based planning activities.

A two-year ethnographic study was carried out across two regional health and care systems in the English National Health Service, focussing on the discharge of stroke and hip fracture patients. Data collection involved in-depth observations and 213 semi-structured interviews.

Information systems (e.g. e-records) represent a relatively stable conduit for routine and standardised forms of syntactic information exchange that can “bridge” time–space knowledge boundaries. Specialist discharge roles (e.g. discharge coordinators) support personalised and dynamic forms of “semantic” knowledge sharing that can “broker” epistemic and cultural boundaries. Group-based activities (e.g. team meetings) provide a basis for more direct “pragmatic” knowledge translation that can support inter-professional “bonding” at the cultural and organisational level, but where inclusion factors complicate exchange.

The study offers analysis of how professional boundaries complicate discharge planning and care transition, and the potential for different communication interventions to support knowledge sharing and learning.

The paper builds upon existing research on inter-professional collaboration and patient safety by focussing on the problems of communication and coordination in the context of discharge planning and care transitions. It suggests that care systems should look to develop multiple complementary approaches to inter-professional communication that offer opportunities for dynamic knowledge sharing and learning.

Building the Right Support, a national plan for people with intellectual disabilities (ID) in England aims to avoid lengthy stays in hospital for such people. Discharge planning is understood to be helpful in facilitating successful transition from hospital to community services, however, there is little guidance available to help those working with detained patients with ID and offending histories to consider how to affect safe and effective discharges. The paper aims to discuss these issues.

In this paper, the development and implementation of a multi-faceted and systemic approach to discharge preparation and planning is described. The impact of this intervention on a range of outcomes was assessed and the views of stakeholders on the process were sought.

Initial outcome data provide support for the effectiveness of this intervention in terms of increased rates of discharge, reduced lengths of stay and low readmission rates. Stakeholders viewed the intervention as positive and beneficial in achieving timely discharge and effective post-discharge support.

People with ID are more likely to be detained in hospital and spend more time in hospital following admission. A planned, coordinated and well managed approach to discharge planning can be helpful in facilitating timely and successful discharges with low risks of readmission.

This is the first attempt to describe and evaluate a discharge planning intervention for detained offenders with ID. The intervention described appears to be a promising approach but further evaluation across a range of service settings is required.

The purpose of this paper is to present lessons learnt through the development of an evaluation framework for a clinical redesign programme – the aim of which was to improve the patient journey through improved discharge practices within an Australian public hospital.

The development of the evaluation framework involved three stages – namely, the analysis of secondary data relating to the discharge planning pathway; the analysis of primary data including field-notes and interview transcripts on hospital processes; and the triangulation of these data sets to devise the framework. The evaluation framework ensured that resource use, process management, patient satisfaction, and staff well-being and productivity were each connected with measures, targets, and the aim of clinical redesign programme.

The application of business process management and a balanced scorecard enabled a different way of framing the evaluation, ensuring measurable outcomes were connected to inputs and outputs. Lessons learnt include: first, the importance of mixed-methods research to devise the framework and evaluate the redesigned processes; second, the need for appropriate tools and resources to adequately capture change across the different domains of the redesign programme; and third, the value of developing and applying an evaluative framework progressively.

The evaluation framework is limited by its retrospective application to a clinical process redesign programme.

This research supports benchmarking with national and international practices in relation to best practice healthcare redesign processes. Additionally, it provides a theoretical contribution on evaluating health services improvement and redesign initiatives.

In order to prevent adverse events during the discharge process, coordinating appropriate community resources, medication reconciliation, and patient education needs to be implemented before the patient leaves the hospital. This coordination requires communication and effective teamwork amongst staff members. In order to address these concerns, the purpose of this paper is to incorporate the TeamSTEPPS principles to develop a discharge plan that would best meet the needs of the patients as they return to the community.

Through a gap analysis, barriers to discharge were identified from the following disciplines: nursing, social work, physical and occupational therapy, psychology, and rehabilitation physician. To improve communication, weekly meetings and twice-weekly huddles were implemented so that concerns regarding discharge obstacles could be identified and resolved. Visibility of discharge dates were improved by use of graduation certificates in patient rooms and green ribbons on patient wheelchairs.

After implementation of this discharge intervention, length of stay was reduced providing cost savings to the hospital, patient satisfaction on HCAHP surveys improved and demonstrated patient satisfaction with the discharge process, and readmission rates improved.

This study demonstrated that effective teamwork and communication can improve patient safety and satisfaction during the discharge period.

This study aimed to analyze and define the concept of readiness for hospital discharge (RHD) in patients with myocardial infarction (MI).

Walker and Avant's approach was used for concept analysis. Electronic text searches were performed using valid databases with “readiness for hospital discharge” and “MI” keywords. The research included quantitative and qualitative studies related to RHD published between 1997 and 2021 in English and Persian. Out of 103 obtained articles, 29 met the inclusion criteria.

In the analysis, the authors identified stable physical state, desirable individual and social conditions, psychological stability, adequate support, adequate information and knowledge, and multidisciplinary care as the attributes of the determinants of RHD. Antecedents were divided into two categories, including preadmission conditions (economic and social, etc.) and postadmission conditions (disease severity and patient health needs, etc). The consequences were also identified as both positive (e.g. self-care) and side effects (e.g. reduced readmission).

The results showed that the concept of RHD in MI patients is a complex and multidimensional condition that applies to all patients on discharge. It is critical for the care team to pay attention to its attributes and scopes in the process of preparing the patient for discharge. It is also suggested that the concept be used as a nursing diagnosis on the North American Nursing Diagnosis Association (NANDA) list. The Association provides nurses with an up-to-date list of nursing diagnoses.

The purpose of this paper is to investigate the regulator's attempt at redesigning the patient care process (PCP) – a core business process in public hospitals – by introducing dichotomous process performance indicators as an innovative management tool intended to align the State health care policy with the everyday management of operations at a hospital ward.

The paper presents an ethnographic case study of redesigning the PCP according to the strategy originating outside the organization. The study employs competing theories that represent alternative epistemological and ontological views of the world in order to produce a tentative explanation of why the intended redesign of the PCP has not fully eventuated. Observational data and opportunistic interviewing are used to answer the research question of whether and how the information and operational flows on the ward were affected by introduction of process performance indicators. A business process redesign framework was employed for data analysis since it better reflects the objectives of the State‐wide initiative and offers a convenient tool in dealing with data complexity.

Introduction of the process performance indicators did not result in redesigning of the PCP as intended by health care authorities. Out of four process performance indicators, only one was consistently implemented, which merely produced a duplication of the previously collected information, therefore adding no value to the PCP. On a theoretical level, the results indicate that the emergent theory rather than the rational agent theory demonstrated a greater fidelity to the empirical observations.

The paper assessed the feasibility of using innovative dichotomous process performance indicators as a tool for redesigning the business process at the ward level, in order to achieve macro‐level policy objectives. The failure to successfully implement a top‐down universal approach to redesigning business processes in health care is likely to reflect a lack of appreciation of emergent rationality that characterizes essential aspects of the PCP.

To map nurses’ actions performed during the care transitions from hospital to home of Covid-19 patients.

A scoping review based on the Joanna Briggs Institute guidelines was carried out. We searched in seven databases: PubMed/MEDLINE, BDENF, LILACS, SciELO, Embase, Scopus, Web of Science and Google Scholar. A two-step screening process and data extraction was performed independently by two reviewers. The findings were summarized and analyzed using a content analysis technique.

Of the total 5,618 studies screened, 21 were included. The analysis revealed nurses’ actions before and after patient’ discharge, sometimes planned and developed with the interprofessional team. The nurses’ actions included to plan and support patients’ discharge, to adapt the care plan, to use screening tools and monitor patients’ clinical status and needs, to provide health orientation to patients and caregivers, home care and face-to-face visiting, to communicate with patients, caregivers and other health professionals with phone calls and virtual tools, to provide rehabilitation procedures, to make referrals and to orient patients and families to navigate in the health system.

The results provide a broader understanding of the actions taken and challenges faced by nurses to ensure a safe care transition for Covid-19 patients from hospital to home. The interprofessional integration to discharge planning and the clinical nursing leadership in post-discharge monitoring were highlighted.

The nurses’ actions for Covid-19 patients performed during care transitions focused on coordination and discharge planning tailored to the needs of patients and caregivers at the home setting. Nurses monitored patients, with an emphasis on providing guidance and checking clinical status using telehealth tools.

This article reports on the experiences and evaluations of piloting health and social care discharge co‐ordinators in acute and community hospital settings. Benefits were felt with regard to length of stay, bed day use, and patient and staff experience, and were particularly notable where a discharge co‐ordinator employed by the community trust was put into the acute hospital setting. The pilots have supported a redesign of hospital discharge processes across Torbay Care Trust and South Devon Healthcare NHS Foundation Trust, and provided the foundation for improved partnership working and integrated service provision.

Interventions to hasten patient discharge continue to proliferate despite evidence that they may be achieving diminishing returns. To better understand what such interventions can be expected to accomplish, the authors aim to critically examine their underlying program theory.

Within a broader study on patient flow, spanning 10 jurisdictions across Western Canada, the authors conducted in-depth interviews with 300 senior, middle and frontline managers; 174 discussed discharge initiatives. Using thematic analysis informed by a Realistic Evaluation lens, the authors identified the mechanisms by which discharge activities were believed to produce their impacts and the strategies and context factors necessary to trigger the intended mechanisms.

Managers' accounts suggested a common program theory that applied to a wide variety of discharge initiatives. The chief mechanism was inculcation of a sharp focus on discharge; reinforcing mechanisms included development of shared understanding and a sense of accountability. Participants reported that these mechanisms were difficult to produce and sustain, requiring continual active management and repeated (re)introduction of interventions. This reflected a context in which providers, already overwhelmed with competing demands, were unlikely to be able (or perhaps even willing) to sustain a focus on this particular aspect of care.

The finding that “discharge focus” emerged as the core mechanism of discharge interventions helps to explain why such initiatives may be achieving limited benefit. There is a need for interventions that promote timely discharge without relying on this highly problematic mechanism.

Transition from inpatient mental health care to community living can be very difficult, as people are at an increased risk of suicide, self-harm and ultimately readmission into hospital. There is little research conducted exploring peer support workers’ (PSWs) lived experiences that could provide insight into the key transitions of care, particularly the support required after discharge from inpatient mental health care. The purpose of this paper is thus to provide a particular insight into what it feels like being discharged from psychiatric care from a PSW’s perspective, how may support be improved post-discharge and what factors might impact the potential for readmission into inpatient care.

A qualitative, phenomenological approach was adopted to explore and describe PSWs’ lived experiences of transitioning from psychiatric care. Four PSWs who were employed by a UK secure mental health facility were recruited. PSW is a non-clinical role with their main duty to support patients, and they were considered for this type of the study for their experience in negotiating the discharge process to better carry out their job as a PSW.

After being discharged from psychiatric care, PSWs experienced issues that had either a negative impact on their mental wellbeing or even resulted in their readmission back into inpatient psychiatric care. This study identified three inter-related recurrent themes – continuity of support, having options and realisation, all concerning difficulties in adjusting to independent community life following discharge. The findings of the study highlighted the importance of ensuring that service users should be actively involved in their discharge planning, and the use of effective post-discharge planning processes should be used as a crucial step to avoid readmission.

A deeper insight into the factors that impact on readmission to secure care is needed. The active involvement of service users in effective pre- and post-discharge planning is crucial to avoid readmission.

Mental health professionals should consider developing more effective discharge interventions in collaboration with service users; inpatient services should consider creating more effective post-discharge information care and support packages. Their lived experience empowers PSWs to play a key role in guiding patients in the discharge process.

This is the first study, to the best of the authors’ knowledge, to explore what it feels like being discharged from inpatient mental health care by interviewing PSWs employed at a forensic mental health hospital by adopting a phenomenological approach. This paper offers a deeper insight into the transition process and explores in detail what support is needed post discharge to avoid potential readmission from PSWs’ perspectives.