International Journal of Gerontology 7 (2013) 65e69

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International Journal of Gerontology

journal homepage: www.ijge-online.com

Review Article

The Past, Present, and Future of Discharge Planning in Taiwanq

Shu-Chuan Lin 1, 2, Shih-Jung Cheng 2, 3, Shou-Chuan Shih 2, 4, Wen-Ling Chang 1, Cheng-Hsin Chu 2, 4,
Jin-Jin Tjung 5 *
1
Nursing Department, Mackay Memorial Hospital, 2 Mackay Medicine, Nursing and Management College, 3 Department of Neurology, Mackay Memorial Hospital, 4 Department of
Internal Medicine, Mackay Memorial Hospital, 5 Department of Family Medicine, Mackay Memorial Hospital, Taipei, Taiwan

a r t i c l e i n f o s u m m a r y

Article history: Discharge planning is an interdisciplinary approach to provide continuity of care; it is a process that
Received 23 April 2012 includes identification, assessment, goal setting, planning, implementation, coordination, and eval-
Received in revised form uation. Discharge planning has been viewed as a major way to enhance a smooth transition for pa-
23 December 2012
tients from the hospital to home or other chronic care units and as a solution to solve problems
Accepted 9 January 2013
associated with postdischarge care. The promotion of discharge planning began in the United States in
Available online 15 March 2013
the 1960s. Nursing scholars from Taiwan learned about the concept of discharge planning from the
United States in the early 1980s and subsequently introduced it to Taiwanese medical institutions in
Keywords:
continuing care,
1985. A policy to promote discharge planning in Taiwan was announced by the Executive Yuan,
discharge planner, Department of Health in 1993. Following the healthcare reforms in 1995, discharge planning has since
discharge planning, been strongly promoted. Studies concerning discharge planning in Taiwan showed some promising
discharge preparing service, results, including increased satisfaction of patients and their families, improved preparation of
Taiwan caregivers, and improved quality of life for patients. However, patients receiving interdisciplinary
discharge planning services were still in the minority. There was no standard evaluation procedure for
interdisciplinary discharge planning, and a high percentage of patients thought that hospitals handled
the postdischarge long-term care services referral procedure inadequately. Despite the positive atti-
tudes toward discharge planning, many physicians still demonstrate an unsatisfactory level of
knowledge and behaviors with regard to discharge planning. To enhance the implementation of
discharge planning, a standard evaluation procedure for interdisciplinary discharge planning and
improved physician awareness concerning the importance of discharge planning are needed. In
Taiwan, the improvement of discharge planning in the foreseeable future is promising with the
accreditation of the procedure and the participation of doctors in efforts to ensure the continuity of
postdischarge care for patients.
Copyright Ó 2013, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier
Taiwan LLC. All rights reserved.

1. Introduction The literature indicates that hospitals often discharge patients

Discharge planning is an interdisciplinary approach to provide
continuity of care. It is a process that includes identification,
assessment, goal setting, planning, implementation, coordination,
and evaluation1 and is the quality link among hospitals,
community-based services, nongovernment organizations, and
caregivers2.
q All contributing authors declare no conflict of interest.
* Correspondence to: Dr Jin-Jin Tjung, Department of Family Medicine, Mackay
Memorial Hospital, 92, Section 2, Chung-Shan North Road, Taipei 104, Taiwan.
E-mail address: jinjin0921@yahoo.com.tw (J.-J. Tjung).
with insufficient planning, poor instruction, inadequate informa-
tion, lack of coordination among members of the healthcare team,
and poor communication between the hospital and community3.
Discharge planning for hospital patients became an issue of great
concern, with an emphasis on continuous postdischarge commu-
nity care in addition to shortened hospital stay, decreased health-
care costs, increased patient and family satisfaction, increased
postdischarge quality of life, decreased readmission rate, and
decreased mortality.
The promotion of discharge planning began in the United State
in the 1960s. In this article, we will review the past and present,
and predict the future development of discharge planning in
Taiwan.

1873-9598/$ e see front matter Copyright Ó 2013, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.ijge.2013.01.011
66
2. Past discharge planning in Taiwan
2.1. Period from 1980 to 1992
In Taiwan, under the traditional model of discharge service,
discharge instructions were provided by primary nurses according
to their own professional judgment.
In the early 1980s, nursing scholars from Taiwan acquired the
knowledge of discharge planning from the United States and sub-
sequently introduced the concept to their nursing colleagues in
Taiwan in 1985.
The earliest article related to discharge planning in Taiwan was
published in the Journal of Nursing in the year 1985 by Change M
under the title “The conceptual framework of discharge planning
and its application”4. This article introduced the framework of
discharge planning, which is composed of four important factors:
(1) the patient and the significant other, (2) available sources for
chronic continuing care, (3) regulations of chronic care, and (4)
primary providers of health care, discharge planning consultant, or
coordinator of discharge planning. The focus of this framework was
centered around the individualized patient and the primary pro-
viders of health care, which have been advocated as key factors in
the success of discharge planning.
During this period, the lack of available sources for continuing
care for chronic conditions and the lack of regulation for out-of-
hospital care were the main problems with regard to post-
discharge care for chronic conditions. In addition, many of the
primary providers were primary nurses, who also lack the power of
coordination.
Well-organized discharge planning was not implemented until
1993.
2.2. Period from 1993 to 2003
In 1993, a policy to promote the implementation of discharge
planning in Taiwan was announced by the Executive Yuan,
Department of Health. In the following year, grants were issued to
four hospitals to develop projects for discharge planning over a 3-
year period. The goal was to create a network of continual health
care through the collaboration of interdisciplinary teams and the
integration of acute and chronic care systems; therefore, patients
could be successfully discharged or referred after acute care in or-
der to receive appropriate continuing care5.
Upon the implementation of National Health Insurance (NHI) in
Taiwan in 1995, discharge planning was strongly promoted. Under
the NHI Bureau In-hospital Control Plan, the term discharge plan-
ning was changed to discharge preparing service5. An additional 25
and 36 hospitals joined this project in the years 1995 and 1996,
respectively6.
In 1998, the results of the 3-year discharge planning project
were published from four hospitals7. All demonstrated a reduction
in the average length of stay at the initial stage of the project, but a
small increase was observed in two hospitals after the NHI was
implemented. The rate of readmission was decreased in one hos-
pital and remained unchanged in the other. The level of patient
satisfaction with regard to discharge planning was measured in
only one hospital, which revealed an increase in patient satisfac-
tion. The promotion of discharge planning had faced many obsta-
cles, including lack of comprehensive and standardized discharge
planning procedure, inadequate communication and coordination
between medical team members, and unwillingness of the patients
and/or their families to participate. Discharge planning still con-
forms to the traditional model, with the nursing staffs providing
discharge services and instructions according to their own profes-
sional judgment.
S.-C. Lin et al.
During the study period, most of the discharge planners were
primary nurses, and only a small number of manuscripts on the
subject of discharge planning were published. These publications
attempted to establish useful evaluation forms and tools for
discharge planning6,7, explain the effectiveness of discharge plan-
ning8e10, and provide a detailed illustration of the process of
establishing discharge planning12.
2.3. Period from 2004 to 2010
Throughout the 10-year project entitled “New Generation
Health Navigation”, NHI promoted the discharge preparing service
at more than 250 teaching hospitals in 200413 and the performance
evaluation of the discharge preparing service was integrated into
the Local Sanitation Bureau’s achievement score since 2005. In the
following year, conferences that focused on the promotion and
observation of the discharge preparing service were organized
throughout Taiwan14.
During this period, although the publications related to the topic
of discharge planning were still few in number, discharge planners
have been expanded from primary nurses to home care nurses15,16,
geriatric nurses17,18, hospice nurses19, and unit-base case man-
agers20. The topics ranged from evaluating the usefulness of
screening tools15,21,22 and the usefulness of discharge planning23 to
the effectiveness of discharge planning for different fields, including
orthopedic patients17,18,20,24, stroke patients15,23, and palliative care
patients19. In addition, an assessment was made of the emergency
nurses’ understanding and experiences with discharge planning25.
2.4. The published manuscripts related to discharge planning in
Taiwan from 1998 to 2010
2.4.1. Studies related to the methods and the screening tools
Since 1996, for one of the tertiary referral centers in northern
Taiwan that developed a protocol of discharge planning, the referral
rate for discharge planning increased from 11.2 patients per month
to 41.6 patients per month in 4 years8.
There are several useful screening tools or method for discharge
planning, including:
1. Blaylock Risk Assessment Screen (BRASS)9. BRASS is a time-
saving tool that offers a reliable prediction of the length of
hospital stay and evaluates whether postdischarge continuous
care is required, especially for patients older than 65 years with
cardiovascular, respiratory, or neurologic disease.
2. Discharge assessment tool for a hospital-based palliative care
unit19. With this discharge assessment tool the completion rate
of written discharge records in a hospital-based palliative care
unit increased significantly, from 38.3% to 88.4%.
3. Seven-item high-risk screening form for orthopedic patients20.
This screening form was designed to gather information such as
patient age, housing status, self-care ability, walking ability,
financial status, medical history, and admission times in the past
years. With a score from zero to two for each item, high-risk pa-
tients are classified as those with a total score of seven or higher.
4. The simple high-risk patient screening form21.
This simple screening form includes three items: (1) cancer or
noncancer patient, (2) activity status, and (3) type of indwelling
catheters on the patient. With a score from 0 to 2 for each item, a
total score of 2 or higher was classified as high risk. The report rate
of high-risk patients was found to improved substantially, from
11.9% to 95.4%, after (1) establishing this simple high-risk patient
The Past, Present, and Future of Discharge Planning in Taiwan
screening form, (2) modifying the discharge planning protocol, and
(3) providing education on the application of this high-risk patient
screening form and the discharge planning protocol for nursing
staff.
5. Patient Needs Rank Assessment Scale for Discharge Planning22.
After being applied to 300 patients within a 1-month trial
period taking place in one medical center in northern Taiwan,
this assessment scale accurately screened the degree of patient
need for discharge planning and users were satisfied with its
use.
2.4.2. Studies on the length of hospital stay and patient satisfaction
A study focus on the length of hospital stay for stroke patients
(n ¼ 171) and craniotomy patients (n ¼ 112) with a nurse-
designed discharge planning project at one medical center in
Taipei City showed that the length of hospital stay was shorter in
the intervention group of stroke patients. In the craniotomy
group, unplanned readmission was less frequent in the inter-
vention group10.
Yin and Duh11 found that the most satisfactory service for 46
patients discharged with tracheotomy was telephone monitoring,
and the most demanding service for patient’s families is to provide
education on the care technique.
In the study on the promotion of the efficacy of discharge
planning through the case management model, Ko et al26 found
that with a case manager and the use of the five-item simple
screening form (including age, conscious level, bladder and anus
control/function, caregiver supply, and readmission period [a
score from 0 to 2 for each item, the total score of 5 or higher was
classified as high risk]), the authors were able to identify potential
care problems and needs of patients after discharge as early as
possible, which not only improved the quality of nursing care and
the nurse-patient relationship, but also dramatically increased
the number of patients receiving discharge planning (from 31 to
74, an increase rate of 138%) and telephone monitoring (from 31
to 253, an increased rate of 716%). Concurrently, the satisfaction
rating for discharge planning also showed a marked improvement
from 2.8% to 44% and the readmission rate was decreased from
12.1% to 4.5%.
Tsai et al27 explored the perception of discharge planning in 489
stroke patients at seven different hospitals in Taipei City. The results
showed that more than 70.0% of patients perceived that the hos-
pital staff had discussed postdischarge care with them carefully, or
health education had been provided. More than three-fourths of
patients thought that hospitals handled the referral of post-
discharge long-term care services inadequately. Up to 94.1% of
patients perceived no follow-up after discharge.
With the early discharge planning services emphasis on as-
sistive technology services, Lin et al28 showed that 50 clients
receiving this service had a higher satisfaction score than the
control group.
With the home care nurse-centered discharge planner and
home follow-up protocol among 100 high-risk patients, Hsu et al15
pointed out that the major factor affecting the discharge care model
was the patients’ physical function. Discharge planning did not
shorten the length of hospital stay, but it did increase the satis-
faction rate of the patients and their families when continuous care
at home was carried out and social resources were used15.
With an emphasis on individualized health education and home
visits following discharge, Shyu et al23 showed that the caregiver-
oriented discharge planning program may improve caregivers’
preparation and the satisfaction of their needs among 76 stroke
survivors’ family caregivers 1 month after discharge.
67
2.4.3. Studies on the discharge planner
In 2004, a study that looked into the job contents and work
conditions of the discharge planner in Taiwan was published by
Yang et al16. The study showed that more than 88 hospitals provide
discharge planning, with nurses assigned as discharge planners.
Among the six different types of job descriptions, the two items
performed least often were the quality of care of the referred
agency and resources utilization and management. The most
important predicting factors for better job performance were in-
tegrated resources and information network, the discharge planner
selection with personality consideration, receipt of education in
discharge planning, and establishment of a multidisciplinary team.
In the following year, Han et al25 studied 32 emergency nurses
regarding their understanding of and experiences with imple-
menting discharge planning in the emergency department setting.
The results showed that the key requirements for the provision of
manageable discharge services include adequate workloads, suffi-
cient time, clear policies, standards of discharge planning, and
enhancement of professional commitment.
2.4.4. Studies on the clinical outcome and readmission rate
In early 1999, it was found that with the implementation of
discharge planning, 80% of patients discharged from the hospital
after tracheotomy could maintain the same or demonstrate
improved activity and physical capability 4 weeks after discharge11.
An investigation looked at the short-term effects of an inter-
disciplinary intervention program on elderly patients with hip
fracture done from September 2001 to November 2003, totaling
159 cases with 72 cases in the experimental group. The results
showed that when the interdisciplinary program included geriatric
assessment, early rehabilitation, in-home rehabilitation, and
discharge planning provided by the geriatric nurse, older people
with hip fractures showed fewer depressive symptoms in addition
to improved clinical outcomes, self-care abilities, and health-
related quality of life within 3 months after discharge17.
During the same period, 126 cases of hip fracture resulting from
a fall were studied for the effectiveness of discharge planning
intervention. The 63 intervention cases demonstrated the benefits
of appropriate discharge planning on improving quality of life,
survival, and the ability to perform activities of daily living while
reducing readmission rates and length of hospital stay18.
The goal of the study by Lin et al24 was to evaluate the effec-
tiveness of a discharge planning program on length of stay, func-
tional status, self-care knowledge, and quality of life for 25 patients
with hip fracture. Self-care knowledge and quality of life were
improved with comprehensive discharge planning.
3. The current state of discharge planning in Taiwan
Since 2011, discharge planning has been integrated into and
become an important part of hospital performance evaluation. One
aspect of accreditation is that hospitals must undertake discharge
planning and ensure continuity of care for their patients. Hospitals
are evaluated on the basis of the level of personnel training, facil-
ities, hospital management, discharge planning, and community
services as well as the quality of medical care they provide.
From 2009 to 2012, setting up the computerized system of
discharge planning was included in the project of the 4-year New
Generation Health Navigation Planning14.
Two of the three articles published on the topic of discharge
planning in 2011 were written by physicians with expertise in
unrelated fields29e31. One study, conducted in the period between
December 2009 to May 2010, which looked at 219 patients
admitted from the emergency department to the general ward and
subsequently discharged to home at one tertiary care referral
68
center in northern Taiwan, showed that integrated postdischarge
transitional care using disease-specific care, telephone monitoring,
hotline counseling, and a hospitalist-run clinic could reduce rates of
postdischarge readmission and death29. The other study focused on
the physicians’ knowledge, attitude, and behaviors toward
discharge planning in one referral center in Southern Taiwan and
showed that (1) based on a total score of 100, the average score of
physicians’ knowledge on discharge planning was 56.7; (2) physi-
cians have mostly positive attitudes toward discharge planning; (3)
with a total score of five, the average score of physicians behaviors
on discharge planning was 3.5; and (4) the logistic regression
analysis showed that physicians’ attitudes and whether they had
received discharge planning educational training were significant
predictors of physicians behaviors. The author suggested that to
enhance awareness of the implementation of discharge planning,
physicians should be made aware of the importance of discharge
planning upon entering the medical profession, namely, by inte-
grating this topic into the medical school education curriculum30.
The latest published study was performed by Su et al31 and
was funded by Taiwan’s Ministry of Economic Affairs in 2009 for
developing the intelligent health information management sys-
tem platform for telehealth care. With this system, the authors
demonstrated that discharged patients could have better access
to health care services when they return to their homes or
communities. The quality of health care is improved, and case
managers are able to monitor patients’ vital signs and other
related health information and to link the significant data in
providing the online health consultations and further referral
services. In this manner, comprehensive and continuous health
care is achieved.
4. The future of discharge planning in Taiwan
With the recent implementation of discharge planning policy by
the Executive Yuan, Department of Health, and the integration of
discharge planning into the Local Sanitation Bureau’s achievement
score, discharge planning is set to become an important part of
hospital performance evaluation since 2011. In addition, the recent
participation of medical doctors in discharge planning studies and
the improvement of the quality of discharge planning in Taiwan in
the near future are promising developments.
5. Summary
Discharge planning in Taiwan was started in 1993 after the
implementation of the policy of discharge planning by the Execu-
tive Yuan, Department of Health. Within these 20 years, hospitals in
Taiwan adopted discharge planning and several studies were
published. The most promising results include higher rates of
satisfaction among patients and families, improved preparation of
caregivers, and improved quality of life for patients. Some contro-
versial findings include the possibility that discharge planning
could shorten the hospital stay and unplanned readmission may
occur less often. However, the number of patients being served
with standard discharge planning and included in the reported
studies remained small. Generally, almost all of the discharge
planners were nursing staff who lacked a standard evaluation
procedure for interdisciplinary discharge planning. More than
three-fourths of patients determined that hospitals handled the
referral of postdischarge long-term care services inadequately, and
up to 94.1% of patients perceived no follow-up after discharge.
Although physicians have positive attitudes toward discharge
planning, based on a total score of 100, the average score of
physician knowledge about discharge planning was 56.7, and the
S.-C. Lin et al.
average score of physician behavior about discharge planning was
70.0.
To enhance the implementation of discharge planning in
Taiwan, development of a standard evaluation procedure for
interdisciplinary discharge planning and improved physician real-
ization concerning the importance of discharge planning are
needed.
Because of the requirement for every hospital to undertake
discharge planning to ensure continuity of postdischarge care for
patients in addition to quality of medical care, quality of medical
professionals, facilities, hospital management, and community
services , the improvement of the quality of discharge planning in
Taiwan in the near future is promising.
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