JACQUELINEJ. B~RMINGHAM

DISCHARGE PLANNING AND HOME CARE 1N T H E U N I T E D S T A T E S

ABSTRACT. As the population ages and governments attempt to control the cost of health care delivery and provide quality care to their citizens, the concepts of discharge planning and continuity of care are emerging as processes that have major impacts on the use of available resources. With the increased emphasis of discharge planning strategies within the nursing process, alternative care settings, particularly the home, are being called upon to provide more comprehensive types of care. Home care service and equipment providers have responded to shortened hospital lengths of stay by developing programs which deliver high quality care to the elderly in their homes. Two cases are presented to illustrate both the nature of discharge planning and the economics of hospital and home-based care. Discharge planners provide a vital link between hospital patients who can be appropriately cared for at home and providers of home care services and home medical equipment. Key Words: discharge planning, continuity of care, home care, alternative care, elders

INTRODUCTION The development of discharge planning programs in the United States followed the pattern of those begun in England at the London Hospital and by the Society for the After-Care of the Insane (Shamansky, Boase, and Horn 1984). Shamansky et al. trace the 'genesis of the idea' of discharge planning in the United States to 1905 and the establishment of the first hospital social services department at Massachusetts General Hospital when a nurse was assigned to investigate "home conditions [to see] that prescribed treatment is carried out." In 1921 The Modern Hospital published an article, "Hospital Convalescents in Their Homes," based on research carried out by a Cleveland nurse with recommendations that paved the way for discharge planning. The greatest impact on discharge planning occurred in 1983 when the United States began to use a Prospective Payment System (PPS) to pay hospitals for the elderly and disabled who were receiving Medicare benefits. The PPS payment schedule is based on research showing that on average a patient with a specific diagnosis would be expected to be hospitalized a specific length of time and to use a specific amount of resources. Since there were so many diagnoses, the Medicare program categorized the various diagnosis into Diagnostic Related Groups (DRGs); thus the system began to be commonly referred to as the DRG system. Under this system a patient who is admitted to the hospital with a particular diagnosis should be expected to stay for a specified length of time and to consume a fixed amount of resources. The DRG system is very complex and takes the patient's complications and comorbid conditions into consideration. The hospital is paid for the patient's admission at a fixed rate depending on the Journal of Cross-Cultural Gerontology 8: 417-429, 1993. 9 1993 Kluwer Academic Publishers. Printed in the Netherlands.

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DRG into which the patient's hospital stay is placed. For example, if a patient is admitted to a hospital for a fractured hip and is treated with surgery, the expected length of stay is 9 days. (See Case#l, pages 11-13). For a patient who stays 9 days, the hospital receives, for example, $9,400. Whether the patients stays 10 days or 5 days, the hospital is still paid $9,400. If the hospital charges are above $9,400, the hospital loses money; however, if the charges are under $9,400, the hospital makes money on that patient's admission. The system is designed to reward efficient hospitals. Since hospitals are being paid a fixed amount of money regardless of how long the patient stays in the hospital, they have a vested interest in moving the patient to the next level of care. Consequently there was great concern that hospitals would discharge patients before they were ready; to avoid this outcome various safeguards were established. For example, hospitals face a substantial financial risk when a patient is readmitted within 30 days of discharge if the admission is for the same diagnosis with which the patient was previously discharged. Another safeguard was the establishment of a system for monitoring the quality of discharge planning for individual patients. This monitoring is done by an outside reviewing program called the Peer Review Organization (PRO). This change in the reimbursement system had a major impact on discharge planners since hospitals needed to focus on moving patients to the next level of care and to do so as soon as they were medically ready. The funding change also had an impact on the provision of care to the elderly in their homes. Because patients were being discharged from the hospital at an earlier stage on the recovery process, home care agencies responded by providing increasingly complex and cost-effective services. Staffing at home nursing agencies was increased; home health aides were trained to care for more acutely ill patients, and competition among agencies increased. Home medical equipment companies worked to make equipment easier and more efficient to use and also enhanced the service component to ensure the safe use of equipment by home nursing staff. The rapid growth of the home care industry during the 1980s can be attributed to the availability of professional, paraprofessional, and ancillary services that are now safely, efficiently, and humanely provided to patients in their homes. In the past decade, advances in technology and the development of efficient and easy to use ventilators, monitors, intravenous pumps, and therapeutic beds have drastically changed the way patients are cared for in their homes (Birmingham 1991). According to Monk and Cox: The demand for home care services for the frail aged and the disabled has been growing relentlessly in recent years. Several factors have contributed to this trend. First, the practice of institutionalization in nursing homes, which intensified during the last quarter century, is now giving way to a more balanced consideration of alternative home based services. Second, the prohibitive cost levels of nursing homes as well as the increase in the number of the elderly, particularly those in the eightyfive and older age bracket, have also stimulated interest in home care services. (1991: ix)

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DISCHARGE PLANNING

The Discharge Planning Process According to O'Hara and Terry: Discharge planning is assessing needs and obtaining or coordinating appropriate resources for patients and clients as they move through the health care system. The term discharge planning suggests a process that occurs when a person is discharged from a facility or an agency. It is more appropriately termed continuity of care planning. (1988: 5) Cu~ently discharge planning is primarily carried out in hospitals and is the process in which the needs of the patient are assessed, the resources to meet those needs are identified, and the patient is moved to the most appropriate level of care. Essentially all health professionals who are involved in delivering patient care services participate in the discharge planning process. However, because of the complexity of patient needs, the range of resources available, the changing status of both, and the need to discharge patients in a timely manner, specialists in discharge planning have taken on an important role. The particular functions of the discharge planner vary considerably from institution to institution, but the basic process is the same. The steps in the discharge planning process are closely aligned to those of the nursing process. The steps include case finding/screening, assessment, planning, implementation, and evaluation. The systematic orientation of discharge planning has a logical process. The first step is one in which the patient who needs complex discharge planning is identified; the next step is the assessment of the needs of that patient and the resources available to meet those needs; the third step is the development of a plan in which there is the best possible match between the needs of the patient and the resources available; the fourth is the action step in which the best possible plan is put into effect; and the fifth and final step is the evaluation of the outcome of the plan.

The Impact of Discharge Planning on the Use of Home Care Services It has been generally noted that over the past few years a shift in health care services has occurred. Hospitals have experienced a downward trend in census levels and are now providing primarily highly intense acute care levels of service. For example, according to data reported in Coulam and Gaume (1991), from 1979 through 1990 per capita admission rates for persons under age 65 decreased from 134 per 1,000 to 78 per 1,000, a decline of about 26%. During the same period the admissions rates for the 65-or-over population peaked at 431 per 1,000 in 1983, then fell by 16% in the next 3 years, stabilizing thereafter at a rate of about 360 per 1,000. Post-operative patients are more frequently spending more of their recuperat-

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ing days at home which has resulted in an increase in the past few years in the number of patients who are cared for at home. Patients with chronic medical conditions are also being treated and cared for successfully at home. In 1992 the National Association of Home Care reported that the number of patients receiving home care services paid for by Medicare grew from 770,000 in 1978 to 1,705,000 in 1991. Of the approximately 11,000 home care agencies in the United States, 5,831 were Medicare-certified, up from 2,496 in 1977. The remaining 5,200 home care agencies are not Medicare-certified either because they do not choose to be or because they do not qualify in terms of the types of services provided. The top diagnoses which account for over 20% of Medicare home health care patients include congestive heart failure, stroke, pneumonia, decubitus ulcer, and myocardial infarction (National Association for Home Care 1992). Patients recovering from hip fracture and the end stages of, for example, cancer, heart, and renal conditions also are cared for successfully in the home. Once patients are assessed for home care needs, the discharge planner must locate the services that are needed by the patient. Since a patient cannot be discharged until a comprehensive plan is in place and until all the necessary services are scheduled, there is ongoing contact between the hospital and the home care agency. Whether a patient is sent home, kept in the hospital, or sent to a nursing facility may be a function of the availability of home care services. The comprehensive assessment of the patient's needs and the arrangements that can be made with the patient, his or her family, and all health providers result in a home care plan that is patient and family centered. (See Tables I and II below for the categories used in assessing patient needs and availability of resources.) Following discharge the ongoing planning for meeting the patient's needs is then carried out by the home care agency professional staff. HOME CARE SERVICES

Types of Home Care Services Available for Patients in the U.S. According to the Council on Scientific Affairs of the American Medical Association: Home care can be defined as the provision of equipment and services to the patient in the home for the purpose of restoring and maintaining his or her maximal level of comfort, function, and health. (1990: 1241) There are various categories of home care services: preventive care, diagnostic care, therapeutic care, rehabilitative care, and long-term maintenance care. The services provided in each of the categories are not distinctly different; the difference lies in the goal of the treatment program. Services available to patients in their homes include nursing care; physical, occupational, and speech therapies; medical social services, and personal care. The home care visits made by health professionals are generally of an intermit-

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TABLE I Categories of Assessment for Patients Needing Discharge Planning: I. Functional needs of the patient: Health perception, health management pattern Nutritional-metabolic pattern Elimination pattern Activity-exercise pattern Cognitive-perceptual pattern Sleep-rest pattern Self-perception/self-concept pattern Role-relationship pattern Sexuality-reproductive pattern Coping-stress tolerance pattern Value-belief pattern 2. Medical needs of the patient: Diagnostic, therapeutic, and monitoring plans 3. Readiness for discharge: Severity of illness, intensity of service, medical stability 4. Rehabilitation potential: Extent of illness Expected disease progression Potential complications Comorbid illnesses (multiple illnesses) Response to therapy Level of dependence Potential for compliance 5. Level of care needs: Hospital care: acute or subacute Extended care facility: short term or long term Home care: acute or long term Adult day care Outpatient/ambulatory care Combination of levels of care 6. Ability of patient to carry out Activities of Daily Living (IADL): Dressing, eating, toiteting, continence, and transferring 7. Ability of patient to carry out or get support for Instrumental Activities of Daily Living (IADL): Grocery shopping, meal preparations, managing medications, laundry, housekeeping, telephone use, managing finances.

tent type; for example, the home care nurse visits the patient for about an hour twice a week as opposed to a full-time private duty nurse who goes to the patient' s home and provides 8 consecutive hours of care. In addition to home care services, the patient may also be receiving community-based services. Community-based services are generally defined as those services not directly related to the medical or nusring care needs of the patient but which provide an environment that will allow the patient to remain in the community in his or her own home. Homemaker services, home delivered meals, chore services such as heavy cleaning, emergency call systems, and adult

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JACQUEL1NEJ. BIRMINGHAM TABLE II Categories of Assessment of Resources Available to Meet the Discharge Needs of Patient:

1. Financial resources: Third party payer/insurance/Medicare/Medicaid Income/assets of the patient 2. Environmental: Location of individual's place of residence Living quarters accessibility to the patient Toilet and hand washing facilities available to the patient 3. Support persons: caregivers such as family or friends Availability of caregivers related to time commitment Availability of caregivers related to distance from the patient Capability of caregivers to carry out prescribed care Availability and capability of caregiver to provide support in ADLs and IADLs 4. Availability of services and products: Professional services, including medical follow-up Oxygen therapy Durable/home medical equipment Disposable products/wound dressings, ostomy care Medications Nutritional support Emergency call systems Transportation services Laboratory services 5. Amount of services needed: Intermittent professional services Twenty-four hour care by professionals Tolerance of the patient of multiple services and self-care needs

day care are all examples of community-based services. (See Tables III and IV for categories of home care programs and the types of services available to persons being cared for in their homes.) Home Medical Equipment Available to Patients in Their Homes

A home care plan would be difficult to carry out without the provision of home medical equipment (Birmingham 1991). The availability of sophisticated medical equipment suitable for use in home care is now possible because of rapid changes in technology (Council on Scientific Affairs 1990). Examples of highly technical equipment include ventilators and other respiratory therapy devices, intravenous therapy pumps including intermittent pumps for antibiotic delivery and continuous pumps for pain control, total parenteral nutrition systems, and cardiac monitors. Other kinds of equipment include hospital beds of various types; wheelchairs that are specifically adapted to meet the needs of the patient; walkers, canes and crutches that have also been adapted with, for example, platforms for resting the arms or wheels for ease in ambulating. Almost any equipment traditionally used

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TABLE llI Types of Home Care Programs Available to Patients in the United States: 1. Hospice Home Care: Under Medicare, hospice is primarily a comprehensive home care program that provides all reasonable and necessary medical support services for the management of a terminal illness. Services covered under Hospice: Physician services Nursing care Home medical equipment and supplies Drugs for symptom management and pain relief Short term inpatient respite care Home health aide and homemaker services 2, Medicare Home Health Care: Home health care is provided if the patient has a need for nursing care, physical therapy, or speech therapy; if the patient is confined to the home; and if the patient is under the care of a physician. Note: Medicare does not pay for 24 hour continuous care. Services included in home health care: Part-time or intermittent skilled nursing care Physical therapy Speech therapy Occupational therapy Part-time or intermittent home health aides Medical social work services Medical supplies Home medical equipment (Durable Medical Equipment) (Most third party payers follow the Medicare coverage guidelines.) Information adapted in part from The Medicare 1992 Handbook U.S. Department of Health and Human Services, Baltimore, Maryland.

in the hospital can be adapted to the home and to the particular limitations in functional capacity of the patient. (See Table V below for a list of the kinds of equipment now available.) This type of equipment has been traditionally referred to as Durable Medical Equipment (DME) since it is durable as opposed to disposable and is related to a medical condition. Because over the past few years there has been an increase in awareness of the importance of home medical equipment and the related services required to operate and maintain it, the phrase D M E has given way to H o m e Medical Equipment (HME) Services and Supplies. ECONOMICS AND HOME CARE To provide the reader with a sense of the practice of discharge planning as well as of the potential cost savings of home care as opposed to hospital or nursing home care two cases studies are presented below. The rates given reflect averages for patients living in the Hartford, Connecticut area.

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JACQUELINE J. BIRMINGHAM TABLE 1V Services Available to Elderly Persons Being Cared for in their Homes:

1. Professional services: Nursing Physical therapy Occupational therapy Speech therapy Medical social worker Home health aide 2. Adult day care: services provided in a congregate setting for a scheduled number of hours per week. Supervision of activities of daily living Health maintenance and restoration Socialization 3. Elderly foster care: services provided on a 24 hour basis in a private non-related family residence. Supervision and assistance of activities of daily living Supervision and assistance with instrumental activities of daily living Management of overall health and welfare 4. Home delivered meals 5. Homemaker services: general household management provided in the patient's personal residence. Changing bed linens, laundry Light housecleaning including washing dishes Meal planning and preparation Mending of the patient's personal clothing Shopping Correspondence including written communications of a business or social nature Assistance with money management in specific situations 6. Mental health counseling services: Mental health evaluation and assessment Individual, group and family counseling 7. Emergency response system: an in-home 24 hour electronic alarm system activated by a signal to a central location. Provides access to emergency services for a patient at risk for a medical, physical, emotional or environmental emergency 8. Respite care services: provision of short-term relief from the continuous care of an elderly patient for the patient's primary caregiver. In-home respite care Out-of-home respite care 9. Transportation services: provided to allow patient to access out-of-home services. In some situations transportation can be provided for the patient to access social and community services, and in others transportation is provided for medical and other professional services. (Information adapted in part from Section 17-134d-164, Connecticut Home Care Program for Elders, State of Connecticut Department of Income Maintenance, Alternate Care Program.)

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TABLE V Home Medical Equipment. Supplies and Services Available to Patients in their Homes: 1. Ambulatory or locomotion aids: Wheelchairs Walkers, canes and crutches 2. Hospital beds 3. Bedside commodes 4. Respiratory care products: Oxygen delivery systems Suction devices Ventilatory assistive devices 5. Accessory appliances: Blood glucose monitoring devices Pressure relieving devices such as air mattresses Ostomy supplies Patient tift devices 6. Enteral nutrition delivery systems 7. Home infusion therapy: Pain control Total parenteral nutrition Chemotherapy Antibiotic therapy Hydration

Case #I Total Hip Replacement - Mrs. Walker Age 75

Mrs. Walker lives alone in a first floor apartment in an urban area. Because of her history of osteoarthritis, she was admitted to the hospital for a total joint replacement. Mrs. Walker also has Type II Diabetes Mellitus, is on a 1500 calorie a day diet, and takes oral medication. Prior to admission Mrs. Walker had attended a pre-admission class on total joint replacement and had all of her laboratory studies, a chest x-ray, and electrocardiogram done. She had been told to anticipate one week length of stay and a 6 week post-surgery recovery period. She was admitted to the hospital the morning of her scheduled surgery. On the second post-surgery day physical therapy was initiated, and on the morning of the seventh post-surgery day, by which time she was already using a walker, Mrs. Walker was discharged to her home where she was expected to continue physical therapy. She was referred to a certified home care agency for nursing care and physical therapy. Nursing visits were also requested to monitor her blood glucose levels and wound healing and to reinforce diet teaching. The nurse was also expected to develop the plan of care for the home health aide who was requested to provide assistance with activities of daily living such as bathing and dressing, meal preparation, laundry, and light housekeeping. Mrs. Walker's cousin offered to assist with other services such as banking and transporting her to the physician's office for follow-up. For comparison purposes only ~he major charges for the hospital stay and

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home care are used to demonstrate the relative costs of care. Physician and medication costs are not inclded in the figures provided below. Mrs. Walker's hospital charges were for room, board, nursing care, and physical therapy and averaged $890 per day for 7 days for a total cost of $6,230. The DRG payment to the hospital was $9,400. The average length of stay for a total hip replacement is expected to be approximately 7 days. If Mrs. Walker had remained in the hospital for the full 6 week course of recovery, the total (additional) charges would have been on the order of $37,380 ($890 x 42). At her home Mrs. Walker was scheduled for a total of 14 nursing visits: 3 visits a week for 2 weeks, 2 a week for 2 weeks, and 1 a week for 4 weeks including the final visit at which she was to be discharged from home car. At $85 per visit the total cost for nursing was $1,190. A total of 16 physical therapy visits over the 6 week period cost $1,360 ($85 x 16). Mrs. Walker was also scheduled to receive a total of 112 hours of assistance from a home health aide: 4 hours a day 7 days a week for 2 weeks, then 2 hours a day 7 days a week for 4 weeks, at an average cost of $18 per hour the home health aide charges amounted to $2,016. In addition a total of $100 worth of home medical equipment, a walker and a raised toilet seat, was purchased. The total cost of 6 weeks of home care for Mrs. Walker was $4,596. Nursing Physical therapy Home health aide Home medical equipment Total cost

$1,190 1,360 2,016 100 $4,666

If Mrs. Walker had been transferred to a nursing home to receive physical therapy and other services for the 6 week period, the costs would have been approximately $9,900.

Case #2 Home Hospice - Mr. Adams Age 68 Mr. Adams was diagnosed 2 years ago with lung cancer, but by the time we are involved it had metastasized to his bones and liver. He, his wife, and 4 adult children wanted him to receive terminal care in the home. At the time of discharge from the hospital Mr. Adams was having problems with pain control, ambulation, and skin breakdown. A consultation with the anesthesiologist on the pain control team resulted in Mr. Adam's being put on sub-cutaneous morphine utilizing a specialized pump allowing the patient to self-administer prescribed doses of morphine sulfate at scheduled intervals. In collaboration with Mr. and Mrs. Adams, the patient's physician, the pharmacist, the primary care nurse, and a nurse from the home hospice program, the discharge planner set up the following plan. A home health aide was to come 8 hours a day to assist with Mr. Adams's care. The patient's 4 children agreed to develop a schedule so that at least one of them or their spouse would be with

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Mrs. Adams each evening. A private duty nurse was to be hired for the night shift so that Mrs. Adams would have time to sleep. In addition orders were placed for a full electric hospital bed with a pressure-relieving mattress, a bedside commode, and a wheelchair to be placed in the patient's home. A few days prior to discharge Mrs. Adams and the children worked with the staff nurses on the unit to learn the basics of care such as bathing, skin care, positioning, and range of motion exercises. They were also instructed in the use of the morphine infusion pump. The average daily hospital cost for Mr. Adams was $1,240 ($990 per day for room, board, and nursing care) and $250 per day for medication. The total cost for the 7 days was $8,680. The DRG payment to the hospital was approximately $5,852 for an average expected length of stay of 7 days. If Mr. Adams had remained in the hospital until his death (which occurred 21 days after discharge), the total additional cost would have been on the order of $26,040 $1,240 x 21). (Physician costs are not included either here or in the home care expense data.) The costs of Mr. Adams's home care are detailed below. Intermittent nursing visits were made during the day twice a week to work with Mrs. Adams and the adult children, to modify the plan of care, and to communicate the progress of the plan of care to the physician. At a cost of $85 per visit the total cost of 7 visits (6 scheduled and 1 at the time of death) was $595. Nursing care for the night shift amounted to i68 hours and cost $6,468 ($38.50 per hour x 8 hours x 21 days). Cost of the morphine, infusion pump, and related supplies averaged $125 per day for a total cost of $2,625. Rental of the hospital bed, bedsie commode, and wheelchair totaled approximately $250. The total cost of 21 days of terminal home care for Mr. Adams cost $12,962. Day Nursing Night Nursing Medications/Supplies Rented Equipment Total Cost

$

595 6,468 2~625 250 $12,962

As these two cases illustrate, once patients have moved beyond the acute stage of their hospitalization and require primarily either rehabilitative or palliative care, the home is both an appropriate and a cost-effective setting for their treatment. CONCLUSIONS Home care is emerging as a cost-effective means of delivering many levels of health care services. The recent initiatives being proposed by legislative bodies at the federal, state, and local levels include coverage of home care services as alternatives to inpatient care in hospitals or nursing homes. We can provide more services to the elderly and disabled by expanding Medicare.

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Long-term care benefits will be phased in, starting with the most neglected area - care in the home and community. (Clinton 1992: 806) Elderly patients and their families are investigating home care services, and managed care organizations are developing long-term care initiatives that include home care services. Because of this change in patterns of health care delivery, there is increased awareness on the part of physicians regarding the uses and benefits of home care. Verby, Newell, Anderson, and Swentko (1991) cite Freymann who notes that: the shift from hospital-oriented to community based health services and a changing public paradigm of health care will shape medical care; i.e. primary care physicians will be the key medical personnel, and the curriculum will have to prepare physicians to function in the new health care system. (p. 10) The home is an appropriate setting for care to the elderly provided the services and the equipment necessary to meet the medical needs of the patient are available. Home care is a cost efficient setting for the delivery of health and medical services and can be prescribed when an appropriate assessment that includes the needs of the patient and the resources available is done. As the level and quality of the service provided in the home increases, as physicians increase their awareness of, and use el, home health and community-based services, and as patients and their families demand more home care, the home care delivery system will take on more importance. Patients will be hospitalized for only the extremely acute period of their illness, and, thus, hospital beds will no longer be needed for care that can and should be delivered in the home. REFERENCES Birmingham, J.J. 1991 Silent Partners in Home Care. Caring Magazine 10(11): 59-61. Clinton, B. 1992 The Clinton Health Care Plan. New England Journal of Medicine 327(1l): 805-811. Coulam, R.F. and G.L. Gaumer 199l Medicare's Prospective Payment System: A Critical Approach. Health Care Financing Review/1991 Annual Supplement. Council on Scientific Affairs 1990 Home Care in the 1990s~ Journal of the American Medical A ssoci ation 263:1241-1244. Monk, A. and C~ Cox 1991 Home Care for the Elderly: An International Perspective. New York: Auburn House. National Association for Home Care 1992 How Rapidly Has the Home Care Field Grown? Basic Statistics about Home Care. Washington, DC: NAI-IC. O'Hare, P.A. and M.A. Terry 1988 Discharge Planning: Strategies for Assuring Continuity of Care. Rockville, MD: Aspen Publishers. Shamansky, &L., J.C. Boase, and B.M. Horn 1984 Discharge Planning: Yesterday, Today and Tomorrow. Home Healthcare Nurse 2(3): 14-21. Verby, J.E., J.P. Newell, S.A. Anderson, and W.M. Swentko 1991 Changing the Medical School Curriculum to Improve Access to Primary Care. Journal of the American Medical Association 266:110-113.

DISCHARGE PLANNING AND HOME CARE IN THE U,S.

Director of Discharge Planning Department of Nursing Har(ord Hospital Hartford, CT 06115 U.S.A.

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Discharge planning and home care in the United States.

As the population ages and governments attempt to control the cost of health care delivery and provide quality care to their citizens, the concepts of...
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