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A Comprehensive Discharge Planning Is Mandatory For Continuity Of Care

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Discuss about the Comprehensive Discharge Planning is Mandatory for Continuity of Care.



The readmission rates for elderly patients of age around 65 years and above within a period of 30 days was about 19 % during the period of 2011 to 2013 in private hospitals according to statistics given by ministry of health, Singapore. In 2013 the rates for readmission of these older patients was 18.5 % in Tan Tock Seng hospital and 21.1 % at Khoo Teck Puat Hospital. These readmission rates were of serious concern for elderly people. Many factors contribute for this readmission like quality of patient care, the transitions from hospital to primary and community care and the care of the follow up including the rehabilitation care. One of the main reason or factor for this also is the environment of the home and family support. These readmission rates can also vary based on the types and ranges of the cases.

The hospitals are at disadvantage as they are not able to provide critical emergency care thus a comprehensive discharge planning is required in which bio psychosocial approach is mandatory for the continuity of care in elderly patients with chronic diseases to prevent readmission. This report contains the biopsychosocial approach which can be followed for such type of patients.  Biopsychosocial approach is a part of discharge planning which if followed properly will prevent readmission of patients.


Biopsychosocial approach for continuity of care:

This is a combination of approaches of three field disciplines including biological, psychological, and social aspects. These factors combined should be followed for proper continuity of care of elderly patients with chronic disease. If these factors are taken care of then the health conditions are improved of elder patients and they are not required for readmission in hospitals (Bayliss et al., 2017).

Biological aspect approach for care:-

  • Creation of a physical environment which needs to be supportive:-

Elderly people having chronic illness have greater chance of developing functioning limitations and disabilities. If the patients are kept in poor living condition then there can be risk of home injury. A supportive physical environment requires safe and accessible living environment for the elderly (Van leon, 2014). The elderly patient with chronic illness can preserve their functional ability by using proper aids like leg braces and wheel chairs. Home accidents can be reduced by modifying the home conditions for safety like installing smoke detector and handrails.

  • Management of diseases:-

The elderly patient and their family should be well informed regarding the health condition, treatment which is going on cost involved in maintenance of the health. The family of the patients should be provided with the information regarding the needs of the elderly patients and also should get the support for decision making. This support can be provided if the health professional visits the patient and their family and give health seminars and education on management of health. For prevention and care of the disease the elderly is suffering comprehensive self care programs have to be done. Some facilities have to kept so that the symptoms of diseases like pain can be sub sized. Proper coordination is required for the delivery of the service. Proper medicines should be given if pains increase.(Bosquette et al., 2014).  


Psychological aspect approach for care:

Psychological care is one of the significant part of the care of elderly patient. Psychological aspects involve the individualized therapy for treatment of behavioral and emotional conditions of elderly patients suffering from chronic illness. Behavioral disturbances is the behavioral or psychological syndrome or a pattern associated with the distress functional disability or difficult to interact with others and environment (Friedrich, 2015). The therapy which is used to reduce anxiety and depression of the patient and the clinical symptoms of the disease is the cognitive behavioral therapy and solution based therapy. It is known from the studies that clinical symptoms can occur in the absence of inflammation or other visible manifestation also (Vandersteen, 2014). In the elderly patient there are many stress inducers relating to the personal situations in the life stage which are responsible to create anxiety and depression and also contribute to symptoms without any visible cause. Thus individual therapy is used which can reduce and eliminate the symptoms and increasing physical and psychological wellness. The behavioral aspect includes aggression, sleep disturbances etc. the aggression of patient can be dangerous for both family caregivers and hospital nurses (Kress et al., 2014). This can be due to symptoms of disease or effects of poor care approach.

Aggression can be controlled by proper counseling of the patient by doctor (Menec , 2006). Sleeping disturbances and other such factors can be reduced by proper medication and counseling by caregivers. There should be proper monitoring of diet , smoking habit or alcohol intake by the caregiver and prevented for proper health care. If exercise is required for the patient then it should be done with proper guidance. There may sometime situation in which the patient can get emotional. This emotion can be related to stress regarding to disease. In such cases patients should be properly counseled with the help of friends and depression psychotherapy should be done. The patient should be able to cope up with the emotions or else this can lead to severe depression which can cause hindrance in the continuity of care (Wallace, 2015). Training should be be given to the patients to scope up with pain and discomfort. When the elderly patient is suffering from chronic disease there is a disruption in daily work for them and their family life. Thus in such cases counseling for family is required and the patients should be helped by the care givers so that they can do their daily activities with ease.


Social aspect approach for care:

Creating a supportive social environment which is supportive:

As there is need for creating a suitable physical environment likewise there is also need for creation of a social environment for better care of elderly patients. Elderly people require a wide range of supports so that they can avoid institutionalization and they can continue to live in the community. Proper community based care should be provided like medical and social service linked to community (Llewellyn et al., 2014). Some community base nursing services should also be engaged for the elderly patients. Many patients of chronically ill nature can get benefit by supportive services which can include home help services transportation services for them. Use of formal and informal social support systems can also be used. The interactions between the patient and their environment can also increase the adapting ability of patient, information access and also motivation of them to survive the tough phase. Formal and informal supports sometimes also complement each other which depends on the nature of services provided (Pergolizzi, 2014). For long time commitment case the flexibility of time can be required which is taken care by informal sources. On other hand formal sources help in providing knowledge and reference. By providing emotional and informational support formal and informal support networks help the elderly patient with chronic diseases.

There are many community based social care programs which provide the patients with assistance in daily living activities delivery of meal and services for transportation. Services from these care workers are required for maintaining daily functioning. Sometimes there should be support from friend’s neighbors who can help the patient in crisis assistance and help during illness by speaking and informal support (Rubinstein, 2014). Programs should be developed to train informal caregivers the skills required during crisis situations like home injury. Elderly patient’s social network not only is a major channel of advice and support during illness but also is a main source for improving health beliefs and knowledge about options in medical field. The support of information for the elderly patient should be improved in community based social health care program. Family members paid care workers and volunteers can be marked to provide support of information to the elderly by doing home visit and contacting them over phone. All these support care systems are important for patients with chronic disease who choose to make informed choice for achievement of health care.



Many research and studies related to that have shown that there are many benefits of discharge planning with older patients with chronic illness. If this planning is not proper then the older patients again are readmission with complications after discharge. These patients should be given proper health service within their community according to the discharge plan. It should be cost effective and proper counseling of the patient and their family should be done. The discharge plan should be properly designed by professionals and implemented to reduce post discharge complications.

With the increase of older patient illness it becomes necessary to do a biopsychosocial assessment of needs and resources required for it. (Pulvirenti, McMillan & Lawn 2014) . Biopsychosocial assessment services are those services which help the patient and their family and providers of health care to manage the psychological, behavioral and social characteristics of illness and its effects to promote good health. The proper assessment is to be made and the needs to be met so that proper care for elderly patients are done. These also include details regarding health insurance and counseling regarding financial needs for coping up with these situations for patients. In this report all aspects regarding discharge planning and assessment of the biopsychosocial needs has been covered for older patients suffering from chronic disease.



Bayliss, E. A., Ellis, J. L., Shoup, J. A., McQuillan, D. B., Steiner, J. F., & Zeng, C. (2017). Association between Continuity of Care and Health-Related Quality of Life. The Journal of the American Board of Family Medicine, 30(2), 205-212.

Bousquet, J., Jorgensen, C., Dauzat, M., Cesario, A., Camuzat, T., Bourret, R., ... & Avignon, A. (2014). Systems medicine approaches for the definition of complex phenotypes in chronic diseases and ageing. From concept to implementation and policies. Current pharmaceutical design, 20(38), 5928-5944.

Friedrich, L. M. (2015). Improving Patient Care Outcomes to Reduce Recurrent Admissions of Patients with Chronic Obstructive Pulmonary Disease.

Kress, H. G., Ahlbeck, K., Aldington, D., Alon, E., Coaccioli, S., Coluzzi, F., ... & Mangas, A. C. (2014). Managing chronic pain in elderly patients requires a CHANGE of approach. Current medical research and opinion, 30(6), 1153-1164..

Llewellyn, H., Low, J., Smith, G., Hopkins, K., Burns, A., & Jones, L. (2014). Narratives of continuity among older people with late stage chronic kidney disease who decline dialysis. Social Science & Medicine, 114, 49-56.

Menec, V. H., Sirski, M., Attawar, D., & Katz, A. (2006). Does continuity of care with a family physician reduce hospitalizations among older adults?. Journal of Health Services Research & Policy, 11(4), 196-201.

Pergolizzi, J., Ahlbeck, K., Aldington, D., Alon, E., Coluzzi, F., Dahan, A., ... & Morlion, B. (2013). The development of chronic pain: physiological CHANGE necessitates a multidisciplinary approach to treatment. Current medical research and opinion, 29(9), 1127-1135.

Pulvirenti, M., McMillan, J., & Lawn, S. (2014). Empowerment, patient centred care and self?management. Health Expectations, 17(3), 303-310.

Rubinstein, D. (2014). Effective Communication as an Important Skill for Quality Care in Elderly Patients. Med. & L., 33, 107.

van der Steen, J. T., Radbruch, L., Hertogh, C. M., de Boer, M. E., Hughes, J. C., Larkin, P., ... & Koopmans, R. T. (2014). White paper defining optimal palliative care in older people with dementia: a Delphi study and recommendations from the European Association for Palliative Care. Palliative medicine, 28(3), 197-209.

van Loenen, T., van den Berg, M. J., Westert, G. P., & Faber, M. J. (2014). Organizational aspects of primary care related to avoidable hospitalization: a systematic review. Family practice, 31(5), 502-516

Wallace, E., Salisbury, C., Guthrie, B., Lewis, C., Fahey, T., & Smith, S. M. (2015). Managing patients with multimorbidity in primary care. bmj, 350, h176.


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