DELIVERY OF HOME CARE SERVICES AFTER-DISCHARGE - WHAT REALLY HAPPENS

Social workers in hospitals develop discharge plans for in-home patien t care with little systematic feedback about postdischarge implementat ion. A telephone follow-up study of patients dis charged from an urban teaching hospital in 1990 was undertaken to determine the extent to w hich discharge plans for home services were carried out and to identif y factors associated with unsuccessful implementation. Overall, 72 per cent of the patients received all, 19 percent some, and 9 percent none of the planned home care services. Great variability was found in ser vice delivery: Registered nurse visits were the most successfully deli vered type of service; 24-hour companions were the least successfully delivered service. Further, over one-third of patients experienced ter mination or reduction of services between discharge and the follow-up interview 21 to 28 days after discharge. Stich unexpected and varied o utcomes suggest the need for development of discharge follow-up progra ms that move beyond hospital walls to ensure that patients receive nee ded services.