Early supported discharge for older adults admitted to hospital: towards an evidence-based and stakeholder informed model of care

Background

Early supported discharge (ESD) is a discharge intervention which aims to link acute and community care by providing multidisciplinary team input in the patient’s own home after hospital discharge, allowing the patient to return home quicker than would otherwise be possible. To date, ESD as an intervention for older adults admitted to hospital has not been extensively explored.

Aim

The overarching aim of this thesis was to explore ESD as in intervention for older adults discharging home from the acute hospital setting.

Methods

This body of work was based upon the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. The first phase involved conducting systematic reviews and meta-analyses to synthesise the totality of evidence regarding an ESD model of care for older adults admitted to hospital with medical complaints, and post orthopaedic surgery. Secondly, a qualitative study explored the views and perceptions of stakeholders; patients, family members/carers and healthcare professionals, on an ESD model of care for older adults. Lastly, a descriptive cohort study was carried out to characterise an existing inreach model of ESD delivered to older adults in the Mid-West of Ireland and describe its impact on patient and process outcomes.

Results

The first systematic review and meta-analysis demonstrated that ESD significantly reduces older adults’ acute hospital length of stay without adversely impacting secondary outcomes such as function, nursing home admission or mortality in those admitted to hospital with medical complaints. For older adults post orthopaedic surgery, the systematic review and meta-analysis identified similar findings in terms of reduced length of stay without adversely affecting secondary outcomes including the number of fallers or function. The qualitative study identified barriers to discharge including the availability of community supports and rehabilitation beds, the challenges that stakeholders face in terms of communication methods across transitions of care and the impact of reduced resources on patient care. Finally, the descriptive cohort study demonstrated that an ESD inreach model of care can have significant effects on outcomes inclusive of functional ability, frailty, and health related quality of life, for older adults admitted to hospital when followed up at 30 and 180 days, without increasing the risk of unscheduled Emergency Department re-presentation(s).

Conclusion

The findings from this thesis serve to inform the future development of ESD as an intervention for the older adult population, with consideration for the identification of the target population, core features of the intervention provided, and outcomes measured.While ESD is broadly conceptualised as a positive process, the transition from ESD to community services is deemed to be problematic and strategies to optimise integration of care and enhance communication across these care settings warrants further consideration.