Older patients and delayed discharge from hospital

Older people (those aged 65 years and over) are the major users of health c are services, especially acute hospital beds. Since the creation of the NHS there has been concern that older people inappropriately occupy acute hosp ital beds when their needs would be best served by other forms of care. Man y factors have been associated with delayed discharge (age, sex, multiple p athology, dependency and administrative inefficiencies). However, many of t hese factors are interrelated (or confounded) and few studies have taken th is into account. Using data from a large study of assessment of older patie nts upon discharge from hospital in England, this paper examines the extent of delayed discharge, and analyses the factors associated with such delays using a conceptual model of individual and organisational factors. Specifi cally, this paper evaluates the relative contribution of the following fact ors to the delayed discharge of older people from hospital: predisposing fa ctors (such as age), enabling factors (availability of a family carer), vul nerability factors (dependency and multiple pathology), and organisational/ administrative factors (referral for services, type of team undertaking ass essments). The study was a retrospective patient case note review in three hospitals in England and included four hundred and fifty-six patients aged 75 years and over admitted from their own homes, and discharged from specia list elderly care wards. Of the 456 patients in the sample, 27% had a recor ded delay in their discharge from hospital of three plus days. Multivariate statistical analysis revealed that three factors independently predicted d elay in discharge: absence of a family carer, entry to a nursing/residentia l home, and discharge assessment team staffing. Delayed discharge was not r elated to the hypothesised vulnerability factors (multiple dependency and m ultiple pathology) nor to predisposing factors (such as age or whether the older person lived alone). The delayed discharge of older people from hospi tal is a topic of considerable policy relevance. Our study indicated that d elay was independently related to two organisational issues. First, entry i nto long-term care entailed lengthy assessment procedures, uncertainty over who pays for this care, and waiting lists. Second, the nature of the team assessing people for discharge was associated with delay (the nurse-coordin ated team made the fewest referrals for multidisciplinary assessments and h ad the longest delays). Additionally, the absence of a family carer was imp licated in delay, which underlines the importance of family and friends in providing posthospital care and in maintaining older people in the communit y. Our study suggests that considerable delay in discharging older people f rom hospital originates from administrative/organisational issues; these we re compounded by social services resource constraints. There is still much to be done therefore to improve coordination of care in order to provide a truly 'seamless service'.