DELIVERY OF HOME CARE
SERVICES AFTER DISCHARGE:
What Really Happens
Ellen PerIman Simon, Nancy Showers, Susan Blumenfield,
Gary Holden, and Xiaochu Wu
Social workers in hospitals develop dis-
charge plansfor in-home patient care
with littlesystematicfeedback about
postdischarge implementation. A tele-
phonefollow-up study ofpatients dis-
charged from an urban teaching hospital
in 1990was undertaken to determine the
extent to which discharge plansfor home
services were carried out and to identify
factors associated with unsuccessful
implementation. Overall, 72 percentof
thepatients received all, 19 percentsome,
and 9 percentnone of the planned home
care services. Greatvariabilitywasfound
in service delivery: Registered nursevisits
were the most successfully delivered type
of service; 24-hour companions were the
least successfully delivered service. Fur-
ther, overone-third of patients experi-
enced termination or reduction of
services between discharge and the
follow-up interview 21 to 28 daysafter
discharge. Such unexpected and varied
outcomes suggest the needfor develop-
ment of discharge follow-up programs
that move beyondhospitalwallsto ensure
thatpatients receive needed services.
KeyWords
discharge planning
follow-up
home care
implementation analysis
CCC Code: 0360-7283/95 $3.00 ©1995, National Association of Social Workers
ince the inception of a prospective payment system (PPS)
S for hospitalized Medicare patients in 1983,length of stay
(LOS)for all patients has decreased significantly.Between
1981 and 1988, inpatient days for Medicare-funded pa-
tients declined 41 percent and for non-Medicare patients
15 percent. LOSfor non-Medicare patients should further con-
tract as PPS systems are expanded nationwide to include all pay-
ers in the near future (Schwartz & Mendelson, 1991). There is
evidence that discharging patients quicker results in their re-
turn to the community sicker, placing their well-being at risk
(Bywaters, 1991; Leibson, Naessens, Krishan, Campion, &
Ballard, 1990;Wood & Estes, 1990). From the outset of the PPS
era, social workers have identified a need for community fol-
low-up studies to determine the postdischarge impacts of PPSs
(Blumenfield & Rosenberg, 1988; Coulton, 1988; Rossen &
Coulton, 1985). However, to date little has been written about
the attainment of goals established in discharge plans.
DISCHARGE PLANNING IN THE PPS ERA
In response to PPS, initial hospital social work efforts were tar-
geted at developing discharge planning mechanisms that would
contribute to cost containment by reducing LOS for Medicare-
funded patients. The focus was on high-risk screening, early in-
tervention, and comprehensive planning, particularly with eld-
erly people, who constitute the preponderance of
Medicare-funded patients subject to the federal diagnosis re-
lated group (DRG)-based PPS. Although discharge planners
were exhorted to maintain quality in the face of pressures to
discharge, there is evidence that discharge planning resources
were devoted primarily to decreasing LOS (Bywaters, 1991;
Wolock & Schlesinger, 1986).
As the PPS era progressed, outcome studies were published
showing that early and comprehensive discharge planning was
effective in limiting both mean LOS and excessive stays
(Berkman, Bedell, Parker, McCarthy, & Rosenbaum, 1988;
Evans, Hendricks, Lawrence-Umlauf, & Bishop, 1989; Holden,
1989; Kennedy, Neidlinger, & Scroggins, 1987) and had a cost-
effectiveimpact on readmission costs (Naylor, 1988;Neidlinger,
5
Scroggins, & Kennedy, 1987). With demonstration
of effectiveness in decreasing LOS, more recent re-
search efforts have turned toward examining other
discharge planning outcomes.
Morrow-Howell, Proctor, and Mui (1991) em-
ployed social worker ratings of adequacy of plan at
time of discharge to measure the product of discharge
planning, defined as the written plan itself. Their
study found that over 23 percent of elderly hospital-
ized patients were discharged with plans rated as
barely adequate or worse, with worse ratings for pa-
tients returning to the community, especially those
whose plans relied on higher levels of informed ser-
vice, than for patients who were placed in rehabilita-
tion facilities or nursing homes.
COMMUNITY AGENCIES REPORTED
GREATER DEMANDS FOR ACUTE
HIGH-TECHNOLOGY CARE, SKILLED
NURSING, AND INTRAVENOUS
ANTIBIOTIC TREATMENTS.
Stuen and Monk (1991) examined patient satis-
faction with discharge planning and service delivery
at four to fiveweeks after discharge in elderly people
discharged to the community from three hospitals.
They found that although most patients were satis-
fied with both their discharge plans and their
posthospital care, a sizable number of the dissatis-
fied subgroup suffered from chronic conditions. The
authors concluded that hospitals seemed to be doing
well at meeting the postdischarge needs of patients
with acute conditions but were less effective in link-
ing patients to community-based services equipped
to meet long-term needs.
The findings of these studies suggest that inad-
equate formal supports in the community cause
some patients to be at greater postdischarge risk. This
idea is supported by a study of the impact of PPS on
771 hospital discharge planners and community pro-
viders in five states (Wood & Estes, 1990). Respon-
dents reported shifts in caseloads of community pro-
viders toward increasing numbers of frail elderly
clients with heavier care needs since the onset of
PPS. Hospital discharge planners reported increas-
ing difficulty in getting their clients accepted by
community agencies, fewer resources available in
general, longer waiting lists, and particular difficulty
in obtaining homemaker and chore services. Com-
munity agencies reported greater demands for
acute high-technology care, skilled nursing, and
6 HEALTH Be SOCIAL WORK / VOLUME 20, NUMBER 1 / FEBRUARY 1995
intravenous antibiotic treatments. Community
agencies also reported increased difficulty in refer-
ring patients to hospitals and to other community
agencies. The authors predicted that formal
community services would be increasingly allocated
to meeting the postdischarge needs of the acute pa-
tient, with growing reliance on informal caregivers
to meet the postdischarge needs of chronically ill
people.
The literature thus suggests that although dis-
charge planning efforts have contributed to LOS re-
ductions under DRGs, sicker patients are returning
to the community with insufficient formal home ser-
vices to meet greater medical and personal needs. At
the time of this study, little was known about the
extent to which plans for postdischarge service de-
liverywere implemented or which patients were most
at risk for failures in delivery.
In 1990the study discussed in this article followed
patients discharged from an acute care hospital into
the community to learn the extent to which planned
home care serviceswere delivered following discharge
and to identify factors associated with service gaps.
The questions addressed were, To what extent were
plans for in-home services carried out? What types
of in-home services were likely to fall short of dis-
charge plan expectations? What were the character-
istics of patients for whom discharge plans were not
implemented? How did service delivery change be-
tween discharge and follow-up? How was length of
stay related to plan outcomes?
METHOD
Setting
The study hospital is a large urban tertiary-care hos-
pital affiliated with a medical school in New York
State that uses an all-payer DRG reimbursement sys-
tem. This setting provided an opportunity to explore
the impact of PPS on Medicaid as well as Medicare
patients. New York provides a higher level of Medic-
aid funding to support home care services than most
other states, and comprehensive services are avail-
able in most areas. Providers, who are licensed by
the state, determine the type and amount of in-home
services needed based on both physician orders and
nursing assessment. In this hospital, cases become
known to social workers through high-risk screen-
ing as well as through patient, family, and profes-
sional referrals. All adult medical and surgical pa-
tients known to the social work department for any
reason during their hospitalization and who were
discharged during October of 1990 were included in
the study.
Procedures
Data were obtained from questionnaires completed
by inpatient social workers at the time of patient dis-
charge, from follow-up telephone interviews with
patients or with family members or other proxies
such as friends or other caretakers, and from the
computerized database of the hospital's medical
records department. All 41 discharging social work-
ers had master's degrees and worked on medical or
surgical services. For each case, discharging social
workers reported the types and amounts of specific
services planned, noting when plans called for pro-
vider in-home evaluation of need for specific ser-
vices rather than preplanned services.They addition-
ally indicated whether they thought services were
needed that would not be provided and whether ar-
rangements had been made for follow-up by hospi-
tal social workers after discharge. Inpatient social
workers rated the discharge plan and patient prog-
nosis on a four-point scale ranging from 1 = poor to
4 = excellent.
Postdischarge telephone interviews with patients
or proxies were conducted by 11 of the 41 discharg-
ing social workers. Social workers volunteered to
conduct interviews and were compensated for their
time. Interviewers did not telephone cases known to
them and were blind to patient data except age, sex,
telephone numbers for the patient and for signifi-
cant others, and discharge date. Contact was first
attempted on the 21st day after patient discharge,
with repeated attempts continuing through the 28th
day during evening and weekend as well as regular
working hours. Interviewers were instructed to ad-
minister questionnaires to proxies only if patients
were not available or were too incapacitated to
respond.
Interviews took approximately 20 to 30 minutes
to complete. The telephone questionnaire consisted
of26 questions and grids for recording information
about the types and amounts (times or days per week
and hours per day) of home care services planned,
received after discharge, and received at follow-up.
Home care services encompassed professional ser-
vices provided by visiting nurses; physical, occupa-
tional, and speech therapists; and social workers and
personal and household care services delivered by
providers such as home attendants, home health
aides, hospice personnel, licensed practical nurses,
housekeepersor homemakers, and personal compan-
ions. Respondents were asked how many days had
elapsed between discharge and delivery of the first
service. Interviewers further asked whether respon-
dents needed services at follow-up that were not be-
DELIVERY OF HOME CARE SERVICES AFTER DISCHARGE
ing provided and attempted to provide the services
requested.
Questionnaires included descriptive questions
about household conditions, the physical and emo-
tional health of the patient and others in the house-
hold, informal help since discharge, and whether
patients had been rehospitalized or institutionalized
since discharge. Respondents provided overall rat-
ings of the discharge plan, of medical care since dis-
charge, and of the patient's overall course since dis-
charge on a four-point scale ranging from 1 = poor
to 4 = excellent.
Information about demographics, hospital admis-
sion status (emergency or elective, private or teach-
ing service case), and diagnoses from the Interna-
tionalClassification ofDiseases, Ninth Edition(ICD-9)
was obtained from the medical records computer-
ized database. For the purposes of this study, psychi-
atric comorbidity was deemed to be present if the
principal or any of six additional ICD-9 diagnoses
were in mental disorders categories. A rough esti-
mate of complexity of illness was derived using dis-
ease staging category scores from the Disease Stag-
ing Clinical Classification System (Gonella, 1990)
based on principal inpatient diagnosis.
Sample
Usable data were obtained for 341 of 442 (77 per-
cent) of cases.Reasons for exclusion of 101 cases were
no telephone number for patient or significant oth-
ers (14 percent), incorrect telephone numbers or no
response despite repeated attempts (58 percent),
patient died following discharge (13 percent), patient
or significant other refused to participate (7 percent),
patient moved out of the area (5 percent), and lack
of necessary translator services (1 percent). Two in-
terviews (2 percent) were completed after the 28th
day and were excluded for that reason.
Significant differenceswere found between the 341
followed and the 101 lost to follow-up. Excluded
patients were significantly more likely (p $ .05) to be
younger (t= 3.1, df= 439), male (Xl = 5.4, n = 441),
and nonwhite (Xl= 6.9, n = 429); to be teaching ser-
vice rather than private patients (Xl = 8.2, n = 441);
and to evidence psychiatric comorbidity (Xl = 6.5,
n = 441). Further, inpatient social workers were more
likely to have considered these patients to be in need
of postdischarge services that could not or had not
been arranged (Xl = 5.5, n = 441) and rated both
discharge plans (r = 3.3, df= 440) and postdischarge
prognosis (t= 3.1, df= 440) worse for these patients
than for the included cases.No differences were found
for other variables, including length of stay and
7
complexity of illness. Findings suggest that efforts to
help were as vigorous for the nonfollowed patients
as for the group followed but that barriers to obtain-
ing postdischarge services were formidable. Lack of
housing, family ties, and other social problems may
have both prevented inpatient social workers from
making arrangements for postdischarge care and pre-
cluded follow-up.
Patients were informants for two-thirds (n = 226)
and proxies for one-third (n = 115) of cases followed
after discharge. Patient ages ranged from 18 to 95
years, with a mean of 62. Two-thirds of the 341 pa-
tients were female (67 percent), and 56 percent were
white. About one-third of patients (34 percent) lived
alone during the first week following discharge. Sixty-
four patients (19 percent) reportedly had been re-
hospitalized and three otherwise institutionalized
(1 percent) by the time of follow-up.
Length of stay ranged from one to 158 days, with
a mean of 17.s and median of 13 days.About 60 per-
cent (n = 205) had been admitted on an emergency
rather than elective basis, and 24 percent (n = 82)
were teaching service rather than private patients.
Admitting diagnoses were grouped into five catego-
ries: heart and other circulatory (24 percent, n = 82),
respiratory and digestive (19 percent, n = 65), malig-
nancy (14 percent, n = 48), and skeletal (10 percent,
n = 34); the remainder (n = 112) were collapsed into
an "other" category. Forty (12 percent) patients evi-
denced psychiatric comorbidity. Complexity of ill-
ness scores ranged from 0 to 3.5, with a mean of 1.4.
Higher scores represent greater complexity.
RESULTS
At the time of follow-up, more than one-half of pa-
tients and more than one-third of other household
members were reported to be in less than good emo-
tional health. Emotional health ratings for the pa-
tients were excellent, 9 percent (n = 30); good, 38
percent (n = 127), fair, 42 percent (n = 139); and
poor, II percent (n = 37). Ratings for other house-
hold members were excellent, 12 percent (n = 26);
good, 51 percent (n = 110); fair, 30 percent (n = 66);
and poor, 7 percent (n = 15). The physical health of
other household members was reportedly better than
their emotional health: excellent,20 percent (n = 43);
good, 58 percent (n= 128); fair, 17 percent (n= 38);
and poor,S percent (n = 12).
Overall the 341 respondents rated the week fol-
lowing discharge as the hardest (72 percent), with 13
percent rating the second week and 15 percent the
interview week as most difficult. Contrasts between
the experiences of the first week and the interview
8 HEALTH Be SOCIAL WORK / VOLUME 20, NUMBER 1 / FEBRUARY 1995
week were examined to detect change patterns.
Changes for the better predominated: 60 percent of
respondents rated patient physical health as better,
23 percent as unchanged, and 16 percent as worse;
52 percent rated patient ability to care for self as bet-
ter, 37 percent unchanged, and 11 percent as worse;
39 percent rated patient emotional health as better,
43 percent as unchanged, 15 percent as worse, and
3 percent did not answer the question; and 20 per-
cent reported more stress, 60 percent unchanged, and
19 percent less stress in the third than in the first
week. Thus, improvements in physical health and
functioning were more frequently reported than im-
provements in emotional health or reductions in lev-
els of stress.
Levelsof informal help were relatively high, with
94 percent (n = 208) of patients living with others
getting help from household members. Seventy-two
percent (n = 245) of all patients received informal
help from people outside the household. Amounts
of informal help were unchanged or increased in 87
percent (n = 297) of cases between discharge and
follow-up.
Twenty-six percent (n = 85) of respondents rated
postdischarge medical care as excellent, 65 percent
(n = 216) as good, 8 percent (n = 26) as fair, and 2
percent (n = 6) as poor. Patients' overall course since
discharge was rated lower than either medical care
or discharge plans: 13 percent (n = 43) rated their
course since discharge as excellent, 53 percent (n =
176) as good, 26 percent (n = 86) as fair, and 6 per-
cent (n = 20) as poor.
Eighty-seven percent of the 41 social workers and
83 percent of the 341 patients or proxies rated dis-
charge plans as good or excellent, reflecting gener-
ally high satisfaction with discharge plans. Inpatient
social workers rated discharge plans slightly higher
at discharge than did study respondents at three to
four weeks following discharge. The social workers'
ratings were excellent, 25 percent; good, 62 percent;
fair, 13 percent; and poor, 4 percent.
Socialwork discharge plans called for 198patients
(58 percent) to receive postdischarge services. Of
these 198 patients, 142 (72 percent) received all, 38
(19 percent) some, and 18 (9 percent) none of the
services. Time elapsed before delivery of the first ser-
vice ranged from 0 to 14days, with the first service in
place by the day after discharge for 86 percent of pa-
tients. In 41 cases (21 percent), discharge plans called
for in-home evaluation of need for services, with no
preplanned amounts of care specified. For the 157
patients for whom services were specified, service
amounts matched or exceeded those called for in the
discharge plan for all services in 90 cases (57 percent)
but fell short for some services in 35 cases (22 per-
cent) and for all services in 32 cases (20 percent).
Outcome of Discharge Plans
Table 1 details the outcome of discharge plans in
terms of number of services planned and whether
each was delivered. Registered nurse visits were both
the most frequently planned and most successfully
delivered type of service, with failure to deliver in
only 8 percent of planned services and delivery of
less-than-planned frequency in 29 percent of
planned services. Home aide/attendant was the sec-
ond most frequently planned and delivered type of
service; failure to deliver occurred in 26 percent of
planned services, and amounts delivered were less
than expected for 29 percent of planned services.
Delivery of rehabilitative services was less success-
ful; delivery of physical therapy failed in 44 percent
of planned services, and delivery of speech and oc-
cupational therapy services failed totally. Seventy-
one percent of planned housekeeper/homemaker
services failed to be delivered, indicating a serious
shortfall in help with home chores. Alarmingly, the
most intensive services, such as home hospice and
24-hour registered nurse care, failed to be delivered
in 72 percent of instances. Overall patterns indicate
that discharge plans were more successfully imple-
mented for services directed at meeting short-term
acute medical needs than for those meeting personal
and household chore or complex medical needs.
Examination of patterns of delivery of services not
planned by social workers revealed a relatively large
number of respondents with housekeeper/home-
maker services (n = 20), perhaps attributable to pa-
tients' hiring private help for performance of house-
hold chores. Deliveryof other unplanned servicessuch
as home aide/attendants (n = 21) and registered nurse
visits (n = 22) may reflect providers' identifying needs
for additional services during in-home visits.
We examined for associations between discharge
plan outcomes and other study variables to identify
characteristics of patients at risk for plan failure. Plan
outcome measures were defined as the number of
days elapsed between discharge and delivery of the
first home care service, the percentage of planned
services delivered, and the percentage of delivered
services for which service quantity equaled or ex-
ceeded the amounts planned. Statistically significant
results are shown in Table 2.
Nondelivery of services and delays in service de-
livery both were associated with discharge plans
calling for postdischarge in-home evaluation of
patient need. This type of discharge plan, there-
fore, proved to be less effective than plans that speci-
fied types of home servicesarranged before discharge.
Nondelivery of home care services also was associ-
ated with more negative respondent ratings of the
discharge plan. The impact was felt most in the sec-
ond week following discharge, which was more likely
to be rated as harder than the first week by patients
who failed to receive one or more home services.

Table 1. Postdischarge Outcomes for Planned Home Care Services (N= 198)
ServicesDelivered
Total Equal to Less
Number ServicesNot or More Than
of Services Delivered Total Than Planned Planned Unplanned
Service Planned n % n % n % n % n %
Registered nurse visits 153 13 8 140 92 77 55 41 29 22 16
Home aide/attendant 137 36 26 101 74 65 64 29 29 7 7
Physical therapist 55 24 44 31 56 17 55 3 10 11 35
Housekeeper/homemaker 7 5 7I 2 29 0 0 1 50 1 50
Speech or occupational
therapist 6 6 100 0 0 0 0 0 0 0 0
24-hourcompanion 3 3 100 0 0 0 0 0 0 0 0
Other intensive services
(24-hour registered nurse,
licensed practical nurse,
home nursing facility, or
hospice care) 11 8 72 3 27 33 33 33

DELIVERY OF HOME CARE SERVICES AFTER DISCHARGE 9

 Respondents who reported receiving lesser
amounts of services than planned were more likely
to indicate that there were unmet home care needs
at follow-up. Patients with admitting diagnoses of
malignancy were significantly less likely to receive
service amounts planned (45 percent of planned ser-
vices) than patients with diagnoses of skeletal dis-
ease (86 percent of planned services). The finding
supports the speculation that providers may be tar-
geting services more to acute conditions than to
chronic ones.
Delay in delivery of the first service was inversely
correlated with LOS.Further, patients who lived with
others following discharge experienced greater de-
lays in service than those who lived alone. Hospital
discharge planners and community agencies may
have assumed that informal resources would tide
such patients over and may have given higher prior-
ity to the more vulnerable patients living on their
own. Delays in delivery were correlated with reported
deterioration in patient functional abilities and
poorer ratings of the emotional health of household
members.
Declines in Services between
Discharge and Follow-up
Declines in services were analyzed for the 180 pa-
tients for whom services were planned and received
and the 19 patients who received unplanned services.
Thirty-four percent experienced either termination
of or a reduction in amount of service by follow-up.
Seventy percent of respondents reported no termi-
nation, 12 percent reported termination of some ser-
vices, and 18 percent reported termination of all ser-
vices by follow-up. Ofthose who continued to receive
the same services, 82 percent (n = 134) got the same
or greater amounts for all services planned, 6 percent
(n = 10) received the same or greater levels for some
services planned, and 12 percent (n = 19) had no
change in services. As shown in Table 3, most of the
service reductions were found in the registered nurse
and home aide/attendant categories.
Results of statistical analyses of associations be-
tween service declines and other variables are shown
in Table 4. Patients who were readmitted before fol-
low-up showed significantly greater termination rates
for services than those not readmitted. It is unclear

Table 2. Factors Associated with Service Delivery Outcomes for

Planned Home Care Services
Primary Factor Associated Factor Statistical Finding
Days elapsed between discharge Length of stay r= -.15
and delivery of first service Percentage of discharge plans calling
for in-home evaluation of need r= .15*
Patient lived alone (.71 days) versus
lived with others (1.3 days) following
discharge t= 2.47, df= 153*
Deterioration in patient's functional
abilities since discharge r= .15*
Poorer rating of emotional health of
household members r=-.21*

Percentage of planned services Percentage of discharge plans calling

delivered for in-home evaluation of need r=-.16*
Days elapsed between discharge and
delivery of first service r= -AI ***
Most difficult week wassecond (.64)
versus first (.85) or third (.86) F=4.6, df= 2*
Satisfaction with discharge plan r=.14*

Percentage of delivered services Admitting diagnosis skeletal disease

with service amounts equal to (.86) versus malignancy (045) F= 3.95, df= 4**
or greater than amounts planned Additional services (042) versus no
additional services (.68) requested
during follow-up interview t =-2.12, df= 151*

*P< .05. **P< .01. ***p < .001.

10 HEALTH Be SOCIAL WORK / VOLUME 20, NUMBER 1 / FEBRUARY 1995

Table 3. Termination or Reduction In Home Care Services at Three to Four Weeks after Discharge
Services Terminated Services Reduced
Service n % n %
Registered nurse visits 43 31 22 16
Home aide/attendant 26 26 7 7
Physical therapist 8 26 2 6
Housekeeper/homemaker 2 100 o o
Speech or occupational therapist o o o o
24-hour companion o o o o
Other intensive services 1 33 1 33

NOTE: Percentages are of the total number of services delivered after discharge for each type of service.

whether services were terminated because patients
were readmitted due to unavoidable exacerbations
of the disease or whether the readmissions occurred
because services were terminated. Termination of
service was also associated with shorter LOS, greater
complexity of illness, increase in levels of informal
care between discharge and follow-up, perceived
unmet needs for home care at follow-up, reported
deterioration in patients' physical and emotional
health, reported deterioration in their functional
abilities, and increased stress. Reduction in amounts
of service was correlated with younger age and poorer
rating of medical care.
Perception of Unmet Needs
Twenty-seven respondents requested help in obtain-
ing additional home care at follow-up. Interviewers
provided four types of help: obtaining services that
were planned but not delivered, obtaining services
that were needed but had not been arranged, advo-
cacy to resolve disagreements or to facilitate prob-
lem resolution, and provision of information. The
greatest perceived unmet need was for home aide!
attendant services (n = 20), with fewer requests for
visiting nurse (4), physical therapist (3), housekeeper
(1), licensed practical nurse (1), and other services
(3). Older patients (r= .11), female patients (t= 2.27,
df = 338), patients with higher complexity of illness
scores (r= .11), patients with discharge plans for in-
home evaluation of need (r = .20), and patients
whose services had been terminated (r = .13) were
more likely to request additional services (p::; .05).
Respondents requesting additional home care were
more likely to report overall increased patient stress

Table 4. Factors Associated with Declines in Home Care Services

Primary Factor Associated Factor Statistical Finding
Percentage of services terminated Length of stay r= .16*
before follow-up Complexity of illness r= .15*
Levels of informal help r= .18*
Additional services (.62) versus no
additional services (.79) requested at
follow-up t=-2.08,·df= 197*
Increased stress r= .15*
Deterioration in patient physical health r= .20**
Deterioration in patient functional abilities r= .18**
Deterioration in patient emotional health r=.17**
Readmitted (.53) versus not readmitted
(.82) before follow-up t = 3.53, df = 48.3**

Percentage of services reduced Age r= .16*

before follow-up Rating of medical care r= -.23**

*P< .05. **P< .01. ***P< .001.

DELIVERY OF HOME CARE SERVICES AFTER DISCHARGE 11

(r = .12) and decreased patient abilities to care for
themselves since discharge (r= .14). Ratings of over-
all course since discharge (r = .12) and discharge
plans (r = .19) were significantly worse for respon-
dents who perceived unmet home care needs at
follow-up.
DISCUSSION
Study results are based largely on participant percep-
tions. More accurate information about postdischarge
home service delivery would have been obtained by
reviewing providers' records or interviewing respon-
dents within a few days as well as a few weeks of dis-
charge. Use of more objective measures such as stan-
dardized scales before discharge and at follow-up
probably would have produced clearer profiles of
patient and household physical and emotional health
and of relationships between those variables and home
care service delivery. In addition, because the study
was conducted at a single hospital, there are limita-
tions on the generalizability of the findings. Within
these limitations, the findings describe outcome pat-
terns for planned home services affecting patients in
an all-payer PPS system and point to areas of needed
focus in patient outcome-related research.
PATIENTS AT HIGHEST RISK FOR
POSTDISCHARGE FAILURE, THERE-
FORE, MAY BE AMONG THOSE LOST
TO FOLLOW-UP.
Earlier discharge planning research related to
DRGs was largely targeted at elderly patients. As
DRG-based reimbursement is extended from Medi-
care to all payers throughout the United States, is-
sues related to completeness of plan implementation
and to consumer satisfaction will become important
concerns for all age groups. Comparison of overall
ratings from this study with findings of two earlier
studies of elderly populations yielded mixed results.
The 83 percent good-to-excellent respondent ratings
of hospital discharge plans reported here was some-
what lower than the 90 percent satisfaction rate found
by Stuen and Monk (1990). Differences may be at-
tributable to variations in age or to use of different
measures. Social worker ratings of discharge plans in
the present study were higher, with 13 percent rating
plans as fair or poor, than those found by Morrow-
Howell et al. (1991), with 25 percent reported as
barely adequate or less than adequate. Differences
may be attributable to the inclusion here of all diag-
nostic groups, variations in age, inclusion only of
12 HEALTH Be SOCIAL WORK / VOLUME 20, NUMBER 1 / FEBRUARY 1995
community discharges, or use of different measures.
As the body of discharge planning outcome research
expands, it is hoped that norms for patient and so-
cial worker ratings of discharge plans and outcomes
can be extrapolated and clinical indicators estab-
lished. Use of common outcome measures will be
helpful in achieving that end.
A high percentage of respondents rated overall
discharge plans either as good or excellent, a positive
statement of the effectiveness of discharge planning
efforts. However, troubling patterns for subgroups
of patients emerged: Discharging social workers
judged patients not included in the follow-up
subsample (21 percent of the total sample) more apt
to be in need of postdischarge services that would
not be delivered than patients in the subsample suc-
cessfully followed into the community. They further
rated discharge plans and patient prognoses signifi-
cantly worse for the lost group. Patients at highest
risk for postdischarge failure, therefore, may be
among those lost to follow-up. The profession needs
to find ways to understand this group better. The
following questions need to be explored: What were
the bases for social workers' judgments? How does
discharge planning outcome actually differ between
this group and patients included in the subsample
followed?How does the difference affect patients and
the health care system? How many of the lost pa-
tients were readmitted, and of those, how many re-
admissions could have been averted through better
delivery of postdischarge care and at what cost? How
many patients with serious conditions were lost to
the medical system? Chart reviews of index and sub-
sequent admissions, follow-up immediately after dis-
charge, and visits to discharge destinations could
provide information shedding greater light on this
group.
Another cause for concern was this study's find-
ing that discharge plans frequently were only par-
tially carried out in the community, with some but
not all of services delivered or lesser amounts deliv-
ered than planned. Although the small subgroup who
failed to receive any planned services is of highest
practice concern, subgroups whose plans were par-
tially implemented or whose home services arrived
late also merit further study. Visits by at least one
outside provider to the home may provide monitor-
ing for acute unmet needs; however, this hypothesis
needs further exploration. A further question is
whether specific types of home services are more
critical than others in cases of partial implementa-
tion. Study findings suggest that nondelivery of all
or some and delayed delivery of planned services may
have adverse effects on postdischarge patient out-
come, an area neglected in research to date. Further,
as hospitals adopt continuous quality improvement
approaches to quality assessment, decreased con-
sumer satisfaction, as reflected by poorer ratings of
discharge plans associated with nondelivery of
planned home services,will be of increasing interest.
Shorter LOS was found to be weakly associated
with delivery delays, providing some corroboration
of the idea that pressure to discharge can adversely
affectpostdischarge service delivery. Pressure to dis-
charge may also have been a factor in those cases in
which discharge plans called for postdischarge evalu-
ation of need. At the study hospital, such discharge
plans usually are formulated when needs for home
serviceare identified as discharge is imminent. After
they complete the in-home evaluation, community
agencies may not be able to provide certain services
or may feel that such services are not necessary.Once
patients are at home, there are fewer alternatives
available.
Last-minute discharge plans may arise from fac-
tors such as abrupt changes in patient needs and sud-
den loss of community supports, high-risk screen-
ing false negatives, and patients' otherwise falling
through cracks in discharge planning protocols. For-
merly, under a per diem-based retrospective reim-
bursement system, discharge would have been de-
layed until discharge planners and agencies fully
developed a plan. With PPS, it is more likely that the
patient will be discharged before the plan is fully in
place. Given the problems reported by patients in
this study, patients with this kind of discharge plan
should have high priority for early postdischarge
follow-up.
Over one-third of patients had experienced re-
duction of home services by follow-up. Service with-
drawal was associated with negative reports on
psychosocialvariables, suggesting that service reduc-
tion affects patient outcomes in critical ways. Find-
ings call into question the presumption that service
reduction occurs as a result of improvement in health
status. It is possible that services were justifiably ter-
minated when medical conditions improved. It
seems likely, however, that at least some service re-
duction resulted from reimbursement practices.
Many insurers pay only for short-term home care
servicesor only for such skilled-nursing services as
dressing changes. For insured patients whose ben-
efits were limited or expired and for uninsured pa-
tients who no longer could afford the expense, home
services may have been withdrawn although medi-
calor personal needs continued to exist. From this
DELIVERY OF HOME CARE SERVICES AFTER DISCHARGE
study's findings, it can be speculated that some
younger chronically ill patients, briefly readmitted,
were discharged with short-term home services de-
signed only to meet acute medical needs, leaving
more complex medical needs unmet when services
were terminated; as a result care was shifted to in-
formal caregivers, emotional health and functional
abilities declined, and readmission occurred as medi-
cal conditions became acute in the face of insuffi-
cient formal supports. Research regarding medical
and psychosocial outcomes related to the nature and
timing of discontinuation of planned home services
will become increasingly important as emphasis
shifts to continuity of care models and as LOS for
non-Medicare patients shortens.
CONCLUSION
In most hospitals, the goal of discharge planning is
the arrangement of a service plan. Commonly, in-
patient social workers' responsibilities are seen as
ending at the point of discharge. It seems clear from
the results of this study that such a view cannot ad-
dress the unexpected and variable outcomes that
befall patients after they return to the community.
Despite time constraints and caseload pressures, the
responsibilities of hospital discharge planners in the
future will of necessity include a discharge follow-
up component that moves beyond hospital walls.
Social workers in hospitals will be called on to de-
velop new strategies and programs for ensuring that
patients receive planned services. With a shift to a
community perspective, patients can be assured of
service that will enable them to survive and thrive
after discharge. HSW
REFERENCES
Berkman, B., Bedell, D., Parker, E., McCarthy, 1., &
Rosenbaum, C. (1988). Preadmission screening:
An efficacy study. Social Work in Health Care, 13,
35-49.
Blumenfield, 5., & Rosenberg, G. (1988). Towards a
network of social health services: Redefining
discharge planning and expanding the social work
domain. SocialWork and Health Care, 13,31-48.
Bywaters, P. (1991). Case finding and screening for
social work in acute general hospitals. British Journal
of Social Work, 21,19-39.
Coulton, C. (1988). Prospective payment requires
increased attention to quality of posthospital care.
SocialWork in Health Care, 13, 19-30.
Evans, R. 1., Hendricks, R. D., Lawrence-Umlauf, K. V.,
& Bishop, D. S. (1989). Timing of social work
intervention and medical patients' length of hospital
stay. Health & SocialWork, 14,277-282.
Gonella, J. (1990). Disease stagingclinical criteria (3rd
ed.). Santa Barbara, CA: McGraw-Hill.
13
Holden, M. O. (1989). Meeting diagnostic related group
goals for elderly patients. Health & Social Work, 14,
13-21.
Kennedy, L., Neidlinger, S., & Scroggins, K. (1987).
Effective comprehensive discharge planning for
hospitalized elderly. Gerontologist, 27, 577-580.
Leibson, c., Naessens, J. M., Krishan, I., Campion, M.,
& Ballard, D. (1990). Disposition at discharge and
60-day mortality among elderly people following
shorter hospital stays: A population based compari-
son. Gerontologist, 30, 316-322.
Morrow-Howell, N., Proctor, E. K., & Mui, A. C. (1991).
Adequacy of discharge plans for elderly patients.
Social Work Research & Abstracts, 27(1), 6-13.
Naylor, M. D. (1988). Comprehensive discharge
planning for hospitalized elderly: A pilot study.
Nursing Research, 39,156-161.
Neidlinger, S. H., Scroggins, K., & Kennedy, L. M.
(1987). Cost evaluation of discharge planning for
hospitalized elderly. Nursing Economics.B, 225-230.
Rossen, S., & Coulton, C. (1985). Research agenda for
discharge planning. Social Work in Health Care, 10,
55-61.
Schwartz, W. B., & Mendelson, D. N. (1991). Hospital
cost containment in the 1980s: Hard lessons learned
and prospects for the 1990s. New England Journal of
Medicine, 324, 1037-1042.
Stuen, c., & Monk, A. (1991). Discharge planning: The
impact of Medicare's prospective payment on elderly
patients. Journal of Gerontological Social Work, 15,
149-165.
Wolock, I., & Schlesinger, E. (1986). Social work screening
in New Jerseyhospitals: Progress, problems, and impli-
cations. Health & Social Work, 11, 15-25.
Wood, J. B., & Estes, C. L. (1990). The impact of DRGs
on community-based service providers: Implications
for the elderly. American Journal of Public Health, 80,
840-843.
ABOUT THE AUTHORS
Ellen Perlman Simon, DSW, is director of
social work, Columbia Presbyterian
Medical Center, 622 West 168th Street, New
York, NY 10032. She is also adjunct
assistant professor, Mount Sinai School of
Medicine, New York. Nancy Showers,
DSW, is assistant director ofsocial work,
Mount Sinai Medical Center, and assistant
professor, Mount Sinai School ofMedicine,
New York; Susan Blumenfield, DSW, is
director ofsocial work, Mount Sinai
Medical Center, and associate professor,
Mount Sinai School ofMedicine, New York;
Gary Holden, DSW, is assistant professor,
Mount Sinai School ofMedicine, New York;
and Xiaochu Wu, MS, is data manager,
Mount Sinai Medical Center, New York.
Accepted July 8, 1993
14 HEALTH & SOCIAL WORK / VOLUME 20, NUMBER 1 / FEBRUARY 1995
vision, creative financ-
ing, paniciparory
management, and
feministvalues to
gain empowerment,
self-help, and politi-
cal ~uity for all
women every-
where. WOMEN 8t
SOCIAL CHANGE: NONPROATS AND
SOCIAL Poucr examines the social, cultural,
and economic influences that shape the global
women's movement. Casestudieshighlightthe
victories and challenges of women's organiza-
tions in seven countries.
• Examine the characteristics and manage-
ment modelsof seven women's nonprofit
organizations.
• Discover what motivates board members,
professional staff, and volunteers to work
without economicincentives,
• Find out how to balance autonomyand
outsidefundingwithout compromising your
organizational program.
• Learnhow to handlepolitical interven-
tion, concerns overgovernance, the adventof
splinrer groups,and other "power" issues.
If you are inrerested in women's issues,
social policy, management, or nonprofit orga-
nizations, WOMEN 8t SOCiAl CHANGE will
help you find solutions and makecritical deci-
sionsin the midst of growthand changeto
assure organizational survival in the furure.
ISBN: 0-871 01-239- I
ITEM #2391 1994
188 PAGFS $24.95
NASW PRESS
To order, send $27.95 (includes $3.00 postage
and handling) to: NASW Press, P.O. Box431,
Annapolis JCT, MD 20701. Or, for easy credit
card ordering, call 1-800-227-3590 (in metro
Washington, DC, call 301-317-8688) or fax
301-206-7989. 'WSC10