Clinical issues - discharge planning in older people

Overview

Discharge planning in older people requires anticipating post-discharge risk (falls, medication error, functional decline, readmission) and coordinating the supports needed to mitigate it - beginning at admission, not the day of discharge
Older patients, particularly those admitted with delirium, functional decline, or from residential care, have a substantially higher 30-day readmission risk than younger patients discharged for the same condition

Poor discharge planning contributes to readmission via several mechanisms: unresolved functional deficits not matched to appropriate support, medication discrepancies/errors at the transition of care, and inadequate follow-up arrangements for ongoing issues identified in hospital

Medication reconciliation at discharge (comparing pre-admission, in-hospital, and discharge medication lists) prevents unintentional continuation/omission of drugs
Functional reassessment close to the actual discharge date (not early in admission) more accurately predicts post-discharge needs, since function can change significantly during a hospital stay
Clear communication with the GP and any community supports, with a structured discharge summary, closes the information gap at the highest-risk transition point in care

Early, multidisciplinary discharge planning (involving nursing, allied health, pharmacy, and the patient/family from admission) rather than a single-discipline decision made late in the admission
Home visits/functional assessment in the actual home environment (where feasible) identify hazards or support gaps that a ward-based assessment cannot

Falls, delirium, functional decline, medication errors at transitions of care, readmission risk

Readmission within 30 days is a recognised marker of inadequate discharge planning (among other causes) and is increasingly used as a quality metric, reflecting how much post-discharge outcomes depend on the process of discharge itself, not just the inpatient treatment

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