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The Effectiveness of Early Screening Discharge-Planning Model

Determine the Effectiveness of Early Screening Discharge-Planning Model and Evaluate the Outcomes of the Discharge Planning on a High, Middle, and Low-Risk Patients Proposal Development.


• Introduction
• Health Issues in Saudi Arabia
• Changing Disease Patterns
• Saudi Arabian Healthcare System
• Theory guiding the study
• Conceptual Module of study
• Explanation of the relationships between the concepts

Determine the Effectiveness of Early Screening Discharge-Planning Model and Evaluate the Outcomes of the Discharge Planning on a High, Middle, and Low-Risk Patients Proposal Development.


Healthcare systems across the world are facing a number of challenges, which include changing pattern of diseases, a shortage of healthcare professionals, inaccessibility of services, and insufficient resources. Given that an increasing population creates a great demand for healthcare services, the shortage of hospital beds due to high admission rates and increased length of stay are some of the challenges that the healthcare system of Saudi Arabia is struggling to overcome. The Saudi Arabian government funds 244 hospitals with a capacity of 33,277 beds (Almalki, Fitzgerald, & Clark, 2011).
However, studies on bed capacity in Saudi Arabian healthcare system have revealed that more than 14,700 beds are needed in order to meet the rising demands for services (RNCOS, 2011).
The shortage of beds implies that the healthcare system needs to formulate ways of increasing hospital bed capacity. Since an increased the length of stay at the hospital contributes to the shortage of beds, the study proposes to examine an early screening discharge-planning model for patients to determine bed capacity in a healthcare center.

Health Issues in Saudi Arabia

A shortage of beds in various healthcare centers in Saudi Arabia has reduced the accessibility of quality healthcare services because healthcare providers are unable to admit some patients. According RNCOS (2011), by 2013, the healthcare system of Saudi Arabia will require additional 14,700 beds to meet increasing demand for healthcare services. Although many factors contribute to the shortage of beds, the length of stay in hospitals by patients is one of the factors that contribute significantly to bed shortages. The length of stay determines bed capacity because the short length of stay increases bed capacity while long length of stay reduces bed capacity. Effective discharge planning is a strategy that may reduces the length of stay, and thus improves bed capacity in a hospital.

In addition, effective discharge planning enhances safety of patients because it guides the selection of post-acute care, which enhances recovery of patients (Masica, Richter, Convery, & Haydar, 2009). The healthcare system recognizes hospital discharge planning as a strategy of creating a seamless transition of care for discharged patients. Accrediting organizations such as the Joint Commission and Center for Medicare & Medicaid Services recommend the application of hospital discharge planning as an intervention to improve the quality of healthcare and patient outcomes (Masica, Richter, Convery, & Haydar, 2009). Therefore, effective discharge planning begins during admission and ends at discharge with patients who have unstable clinical conditions stay for a longer period.

The density of beds in hospitals varies from one country to another depending on the economic and social conditions of the people. Since the United States is a developed country, it has 30 hospital beds per 10,000 populations (World Health Organization, 2013). Availability of effective discharge planning mechanism in the United States has reduced average length of stay to about 5 days (World Health Organization, 2013). Comparatively, Saudi Arabia has a bed density of 22 hospital beds per 10,000 populations (World Health Organization, 2013). Although the bed capacity is significantly low, the average rate of a person’s stay in a hospital is about 8 days. Lack of a proper discharge method is the chief cause of the long period of stay.

Healthcare systems in the United States and most European countries provide post-acute care to the elderly or disabled patients who are unable to perform activities of daily living due to their illness or age. In Saudi Arabia, the healthcare system provides minimal post-acute care. Normally, the post-acute care in Saudi Arabia is for the elderly people who are poor and do not have any family members to take care of them. Since the Saudi Arabian culture expects children to take care of their parents, most of the elderly people do not seek post-acute care. Conventionally, parents bring up their children by educating them so that they can contribute to the society by taking care of them during their old age.

Changing Disease Patterns

There are several trends driving the demand for healthcare. Currently, Saudi Arabia has made enormous economic growth and improved the lives of its citizens in various aspects of life including health. However, despite the improvements in the healthcare system, the emergence of modern diseases such as diabetes, obesity, and hypertension coupled with the associated chronic complications reduces the health standards of Saudi Arabians (Almoudi, Attar, Ghabrah, & Al-Qassimi, 2009). The occurrence of chronic conditions due to aging or diseases usually compels family members to seek management and treatment interventions from a nearest hospital. In this view, chronic conditions pose a significant burden to the hospital because patients stay for long periods in spite of the fact that hospitals have a low bed capacity.

In addition, despite the presence of preventive measures, there is an increase in the incidences of road accidents in Saudi Arabia. These accidents have increased the demand for healthcare services, which subsequently lead to the shortage of beds in various hospitals. According to Al-Shehri and Abdel-Fatta (2007), most of the traumatic accidents cause quadriplegia (72. 8%), which requires long-term treatment in the hospital. Thus, long-term treatment of patients causes congestion in the Saudi Arabian hospitals, yet they have limited bed capacity. Because there is limited post-acute care, there are few sites where patients can receive rehabilitative care outside the hospital.

Saudi Arabian Healthcare System

The Saudi Arabia healthcare system comprises of primary care level (health centers), secondary care level (general hospitals), and tertiary care level (specialized hospitals). The healthcare system provides geriatric and related healthcare services to patients admitted to general hospital beds during their initial treatment. However, after undergoing treatment, healthcare providers find it difficult to discharge patients because cheap alternative facilities are limited while patient’s relatives are unwilling to provide care at homes. Hence, the healthcare system then bears the burden of taking care of the neglected patients or the elderly people. Masica, Richter, Convery, and Haydar (2009) state that healthcare systems should design effective programs that reduce the cost of care and improve the safety and quality of care. In this view, the healthcare system of Saudi Arabia should develop effective discharge planning, which may reduces bed congestion and improves patient outcome during post-acute care.

The Saudi Arabian Ministry of Health has constructed six long-term hospitals for post-acute care (called Nagaha). In 1987, the healthcare system established the first post-acute care hospital in Riyadh, and subsequently established similar hospitals in Qassim, Baha, Medina, Asir and Taif (Kingdom of Saudi Arabia Ministry of Health, 2013). The established hospitals are long-term care institutions that provide appropriate healthcare services to patients referred from acute care hospitals. Since the available data of chronic illnesses, the elderly and the disabled people is limited in tertiary hospitals, there is a need to explore the effectiveness of the discharge plan by assessing patient outcomes.
Increasing demand for healthcare services is an issue that is stretching available resources in the healthcare system. Shortage of beds in hospitals due to length of stay is a common problem in the Saudi Arabian healthcare system. The problem being investigated is the shortage of beds experienced in most Saudi tertiary hospitals, which occurs due to increased length of stay in hospitals by patients with chronic illnesses, the elderly, and the disabled people. The purposes of the proposed study are to describe the post-acute care needs, determine the effectiveness of early screening discharge-planning model and evaluate its outcomes among patients with high, middle, and low risks.

Theory guiding the study

Nursing’s body of knowledge expands from grand theories to mid-range theories, and nursing research is based on nursing theories that drive practice. Grand theories are broad and do not generally lend themselves to testing, but nursing must continually base its practice and research on theory that gives a basis for elements being studied. The theoretical framework used in the study is Orem’s Theory of Self Care. The central concepts in this nursing theory address self-care deficits and nursing’s role in helping the patient learn to care for self again. Orem’s theory takes into consideration internal and external factors, which may include the home environment, social support systems, and community resources that affect a person’s ability to engage in self-care as they prepare for successful discharge home. The self-care paradigm incorporates self-care, which is caring for oneself to promote well-being and optimal health, and its relationship with the self-care agency, described as a person’s abilities to perform self-care behaviors necessary to maintain health. This can be influenced by several factors such as age, gender, community resources, family systems, environmental factors, cultural influence, current health state, and healthcare system (e.g. treatment recommendations) (Kearney-Nunnery, 2008).

Self-care agency is a spontaneously learned and develops out of the need for individuals to interact with their current health situation and environment. It specifically encourages them to overcome obstacles and allow them to engage in care that results in successful self-care practice.
Orem stressed the importance of understanding the care needs of patients and thought of this as the starting point in the patient’s illness, which parallels the concept of asking patients early in their hospital stay what they perceive to be goals and barriers for discharge. Evidently, it engages the patient in the discharge process and encourages them to collaborate with the healthcare team to anticipate discharge planning barriers. In this way, the system allows the interdisciplinary team to assist individuals in decision-making about their discharge plan, provide education to overcome barriers, and include family and community support systems in care planning. In addition, it encourages them to allow for the identification of social, cultural and ethnic values and beliefs that can potentially prevent an individual from overcoming self-care deficits. This theory has been used extensively in the acute- care setting as well as populations invested in health maintenance, symptom management, and chronic illness which are but a few of the issues facing patients who are contemplating complex discharge planning (Moore & Pichler, 2000).

According to Mitchell, Ferketich and Jennings (1998), there has been a shift in the emphasis placed by conceptual framework on management and evaluation of healthcare quality. It has shifted from focusing on structures to focus on processes and outcomes. The study of healthcare quality has received much motivation and focus from Donabedian’s model (1966) that emphasizes on structure, processes and outcomes as the major elements of healthcare (Donabedian, 2005). Mitchell Ferketich and Jennings (1998) further adapted the model to expand on system and patient factors.

The Mitchell, Ferketich and Jennings (1998) model was adapted by McBryde-Foster and Allen (2005) who brought attention to the continuum of care as a summative entity whereby the patient progresses “over time, between environments of care, through events called transition points” (McBryde-Foster & Allen, 2005; Mitchell, Ferketich & Jennings 1998). Other studies have expanded on the McBryde and Allen (2005) model to organize concepts of discharge planning, transitional care and continuity of care into a comprehensive, temporally dynamic conceptual framework. The authors defined important sub-elements that included discharge planning process, coordination of care, transitional care process, and continuity of care for the achievement of quality care outcomes.

The discharge planning process is an interdisciplinary process that occurs within a healthcare setting with the purpose of assessing, planning and providing intervention management for continuing needs requiring follow-up care after hospitalization by arranging for community services and/or health professionals.

Coordination of care focused on the process for the integration and sequencing of activities of patient care (Reid, Haggerty, & McKendry, 2002) with an emphasis on linking planning and management activities across different providers within the same setting.

The transitional care process was the transmission of a range of services and information across hospital and community locations and healthcare providers (home or agency) designed to promote the safe and timely transfer of patients from one level of care to another (Coleman & Boult, 2003).
Continuity of care was defined as mechanism used by a hospital system or agency to decrease information asymmetry and increase goal alignment between patient and care providers (Kohn, Corrigan & Donaldson, 2000). Continuity of care may be an outcome variable whereby the patient receives consistent, planned care and services across settings (Coleman & Boult, 2003).
Informational continuity of care existed when information experienced in a patient’s past was available and used to provide current patient care. The EHR was a technological tool to create a chronological library of patient healthcare over time and to provide information that can be used to bridge service across providers.

Relational or interpersonal continuity of care referred to the ongoing therapeutic relationship between the patient and the provider characterized by mutual trust and the provider’s responsibility for future care (Reid, Haggerty, & McKendry, 2002). Managerial continuity of care included the use of protocols and guidelines to assure care and treatment provided by one or more provider in a connected, orderly, coherent, complimentary and timely fashion (van Servellen, Fongwa, & Mockus D’Errico, 2006).
Using the Holland and Harris model, this study focused on the hospital setting. Specifically, this study used the data collected by nurses from patients during the HER nursing admission history process. This process was set to support NCM referral for discharge planning. The period of interest for this study was the first 24 to 72 hours from the patient’s hospital admission. The Donabedian Model is conceptual in nature and seeks to provide a good framework through which healthcare settings can examine their services and evaluate quality of care. The model requires information about quality of care to come from three areas- structure, process and outcomes. Accordingly, each category has its meaning within the framework. First, ‘structures’ refer to the context in which the healthcare is provided, including the staff, equipment, buildings and financial sources. Secondly, processes are the relationships between providers and clients. The outcomes refer to the impact of healthcare delivery on patients and the general population.

A number of other frameworks are in existence. For instance, Bamako Initiative and the WHO-Recommended

Quality of Care Framework are effective. However, the Donabedian Model is the dominant method for assessing healthcare quality.
A chain of three boxes is used to represent the model in theory. Each box represents each of the three elements of healthcare- structure, process and outcomes. Unidirectional arrows connecting the boxes are used to describe how the assessment process moves within the system. In addition, the boxes represent the type of information collectable from each of the three areas of quality healthcare system. Accordingly, the structure box shows the factors that have an influence on the context of healthcare delivery. These factors control the process and manner of providing healthcare, including the actions and behaviors of the personnel involved. They are the measures of the average quality of care given in the healthcare system of a given facility.

Processes box represents the activities involved. For instance, it includes such activities as diagnosis, medication, treatment, patient education and preventive care. In some cases, the process box may also be used to show the actions taken by patients and their families with an aim of improving the outcomes. These processes can also be classified into other categories such as technical and interpersonal processes. According to the model, measurement of the process is equal to the measurement of quality of care because the processes box contains all the activities of healthcare system.
The outcomes box contains all the resultants of the healthcare system. It must include all the effects and impacts of delivery on the patients. Such effects include changes on behavior, health status, knowledge and satisfaction. The primary goal of healthcare is to ensure that patient conditions are improving.
Researchers must use a large sample population and a long follow-up period in studying these aspects. This is difficult because outcomes take a long time to show evidence of success or failure.
It is worth noting that the model lacks a specific definition of quality care. It also shows that each of the three elements of healthcare has advantages and disadvantages that make it necessary for researchers to evaluate the connections between them. By drawing these connections, researchers create a chain of causations that may be used to understand the concept and systems and in designing experiments or interventions.

Conceptual Module of study

The subjects of the study are the patients admitted to hospital in Saudi Arabia. Each patient will have his or her own score of ESDP. A Score of 10 or more patients considered to be at risk for complicated discharge plans will be used to Identify and prioritize patients appropriate for early DP. Cutoff score determines the people to be considered in the Transitional care as post-acute referral. Effective discharge planning is a strategy that may reduce the Average length of stay in a healthcare (ALOS). Thus, it improves bed capacity in a hospital.

Explanation of the relationships between the concepts

The relationship between ESDP score and Transition of Care (referral number) being practicing in Saudi Arabia is the first phenomenon to be explained. Secondly, an explanation of a possible relationship between ESDP score and Bed capacity in a healthcare center should be developed. Thirdly, an explanation of a possible relationship between ESDP score and the ALOS in a healthcare center is important in the process. The fourth explanation will involve the possible relationship between Transition of Care and the ALOS in a healthcare center. The fifth explanation will describe the possible relationship between Transition of Care and Bed capacity in a healthcare center. The sixth explanation will focus on the relationship between Transition of Care and Post-acute care demand. The last phenomenon is the possibility of a relationship between ALOS and Bed capacity in a healthcare center.


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