Clinical Question

Do individualized discharge plans shorten the length of hospital stays or reduce hospital readmission rates?

Evidence-Based Answer

Older patients (i.e., 60 to 84 years of age) who are hospitalized but not undergoing surgery and who have individualized discharge plans have shorter hospital stays compared with patients who receive standard care only (mean difference = −0.73 days; 95% CI, −1.33 to −0.12). (Strength of Recommendation [SOR]: B, inconsistent or limited-quality patient-oriented evidence.) Patients with individualized discharge plans have lower rates of unscheduled hospital readmissions during an average of three months of follow-up (absolute risk reduction [ARR] = 2.9%; 95% CI, 0.8% to 7.1%; number needed to treat [NNT] = 34; 95% CI, 14 to 125).¹ (SOR: B, inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Delays in hospital discharge occur when a patient is medically fit to be discharged home or to another setting, but arrangements for transfer and subsequent care are not in place. In the United States in 2014, the average length of stay for any hospital admission was 6.1 days, and in government-affiliated hospitals it was 10.3 days.² Delayed discharges place a significant burden on the health care system by decreasing the number of available hospital beds. They lead to worse patient outcomes, can cause distress to patients and their families, and increase overall health care costs.^3,4 Individualized discharge plans may decrease the duration of hospital stays and reduce the risk of hospital readmissions by reconciling treatment plans, educating patients and families, and facilitating outpatient follow-up.^1,3,4

This Cochrane review included 33 randomized controlled trials, 13 of which were conducted in the United States, five in the United Kingdom, three in Canada, and the remaining in Europe, Asia, and South America. There were 12,242 participants with an average age ranging from 60 to 84 years. Follow-up ranged from two weeks to nine months, with an average of three months. Exclusion criteria in most trials involved additional interventions, including the delivery of post-discharge care; discharge planning that was part of a multicomponent intervention; or the involvement of discharge plans for the comparison group. Primary outcomes included length of hospital stay, unscheduled readmissions, patient health status (e.g., mortality, functional status, psychological health), patient satisfaction, and health care resource costs.

Individualized discharge plans included the documentation of an inpatient assessment tailored to patient needs and communication between patients, their families, and relevant medical professionals about the discharge plan. Of the 33 trials included in the study, 30 incorporated an education component that provided patients with information about their health condition, medications, and post-discharge arrangements. The control groups received standard care with no individualized discharge plan.

In older adults who were hospitalized and not undergoing surgery, implementation of an individualized discharge plan decreased the mean length of hospital stay (−0.73 days; 95% CI, −1.33 to −0.12; n = 2,113) compared with no individualized discharge plan. Patients admitted following surgery, or with any condition including surgery, had little to no improvement in the length of hospital stay when individualized discharge planning was implemented. Of the 17 trials that assessed unscheduled readmission rates, 10 showed lower readmission rates (in an average of three months from discharge) for patients with individualized discharge plans (ARR = 2.9%; 95% CI, 0.8% to 7.1%; NNT = 34; 95% CI, 14 to 125). The review did not demonstrate any clear effect of individualized discharge plans on patient mortality, functional status, or psychological health. It is uncertain whether there was any difference in overall hospital, primary, or community care costs when discharge planning was implemented. Patient satisfaction was measured by different questionnaires, and results were not consistent across the eight studies that measured it.

Limitations of the review included variations in how discharge planning was implemented, because there was no single intervention included in all 33 trials. Most interventions included a patient education component, although there was variation in the personnel implementing the discharge plan (i.e., nurse, pharmacist, discharge coordinator, or physician). A range of medical diagnoses was seen in the included trials (e.g., heart failure, stroke, mental health), and different medical conditions required different levels of discharge needs. Timing of discharge plan implementation varied during the hospital stays.

The National Institute for Health and Care Excellence recommends that all clinicians in hospital and community settings plan hospital discharge with patients and their families, caregivers, or advocates. They should ensure that the discharge is collaborative, patient-centered, and suitably paced so the patient does not feel that their discharge is sudden or premature.⁵ To optimize the discharge process, family physicians working in an inpatient hospital setting should consider multidisciplinary, individualized discharge plans for older patients admitted for a medical condition.

The practice recommendations in this activity are available at https://www.cochrane.org/CD000313.

The opinions herein are those of the authors. They do not represent the official policy of the Uniformed Services University of the Health Sciences, the U.S. Department of Defense, or the U.S. Air Force.

Editor's Note: The ARRs, CIs, and NNTs reported in this Cochrane for Clinicians were calculated by the authors based on raw data provided in the original Cochrane review.