Need Assessment and Follow-Up of Discharge Planning Referral to Post-Acute Care for Aged Patients

To increase the efficiency of health care and control medical costs, adequate discharge planning is one of the effective strategies. One of the main purposes of discharge planning is screening patients’ need of post-acute care and arranges proper care service after discharge for keeping continuous care, avoiding medical adverse events, decreasing costs and enhancing prognosis. This project will based on 6 different objectives, and the main methods of each objective are as below: The first year: Objective 1：To understand the common diagnosis and comorbidity of discharged elderly in Taiwan, and to summarize the different cluster patterns according to their characteristics. Objective 2：To explore the health care utilization of aged patients within 60 days after discharge, and estimates the readmission rate, medical expenses and mortality. Objective 3：To compare the evaluation outcome of discharge planning and the need assessment of continuous services between different cluster patterns, and develop the case-mix grouping for discharged elderly by decision regression tree. The second year: Objective 4：Review references related to post-acute care need assessment, and develop the screen tool and care plan assessment preliminarily. Discharge decision support system (D2S2) was applied to screen post-acute care need in USA and comprehensive geriatric assessment was applied to plan care service in UK. We need to explore more adequate indicators for need assessment and apply them to Taiwan aged patients. Objective 5：Survey the need of post-acute care in aged discharged patients by the developed tools, and confirm the predict power of screen tool and care plan assessment tool. One medical center and two district hospitals are involved in our study. Random sampling will be used to the discharged aged patients and our researchers will inquire about the willingness of joining this study. We will recruit 300 patients at least. The third year: Objective 6：Keep follow-up and interview to the aged patients at the 15th, 30th, 90th days after discharged, and compare the readmission rate and institutionalized whether the post-acute care needed. Besides, we will follow the care service use and potential barriers for post-acute care needed patients.