Hospital discharge of frail, elderly patients with complex care needs: a problem or a challenge?

Introduction: The increase in patients with chronic disease that require on-going care is creating difficulties for the public health system, which have prompted recent attempts to remodel the system with a generalized reduction in the number of hospital beds and the implementation of services designed to promote home health care. Intermediate care is an opportunity to support timely discharge from acute-care facilities and promote functional recovery, but its efficacy requires a strong, complete and comprehensive assessment to ensure appropriate admission.
Materials and methods: The Care Continuity Service of Rimini is a multiprofessional team that supplies support and counselling for acute hospital wards and training for nursing and medical professionals to develop their assessment skills.
Results: A questionnaire filled out by the staff of acute-care internal medicine wards in the Greater Romagna Area has revealed ambiguities in the use of terms like €˜â€˜social'' and €˜â€˜complex care needs.'' It also documents difficulties in the early identification of patients likely to experience problems if they are discharged from the hospital directly to their homes.
Discussion: To ensure prompt identification of these patients, we must identify/develop a screening instrument or clinical-functional method that can be used in acute-care hospital wards to plan discharges. The aims of intermediate care are to reduce hospital stays and improve continuity of care, but specific know-how and expertise are needed if these goals are to be met. Specific staff training programs and a patient-centred model are essential to ensure an acceptable cost-benefit ratio.