SCIE research briefing 12: Involving individual older patients and their carers in the discharge process from acute to community care: implications for intermediate care

Alphabetical references

(1) Age Concern, British Geriatrics Society. (2002). Implementation of the National Service Framework and intermediate care seen from geriatricians' and older people's perspectives: results of two national surveys; reasons for optimism, reasons for concern. British Geriatrics Society. This is a summary of the findings of surveys into the effectiveness and viability of the NSF for older people, especially in relation to intermediate care.

(2) Andrews J., Manthorpe J., Watson R. (2004). Involving older people in intermediate care. Journal of Advanced Nursing, 46 (3), 303-310. This paper explores the concept of intermediate care and to identify trends and existing evidence of user involvement in care. It also suggests a possible way forward for the development of a more 'user sensitive' approach. Abstract available

(3) Asthana A., Halliday J.E. (2003). Intermediate care: its place in a whole systems approach. Journal of Integrated Care, 11 (6), 15-24. This paper evaluates an intermediate care system in Cornwall.

(4) Barnes M., Bennett G. (1998). Frail bodies, courageous voices: older people influencing community care. Health & Social Care in the Community, 6 (2), 102-111. This paper reports on the evaluation of a project in Fife Scotland to enable older service users to develop a collective voice to express their wishes and concerns to health and social services. Abstract available

(5) Barnes M., Cormie J. (1995). On the panel - good hospital discharge. Health Service Journal, 2 March, 30-31. This article briefly describes the findings of the Fife User Panel about older patients and carers concerns and recommendations regarding hospital discharge.

(6) Barrett J., Goh H., Todd C., Barclay S., Daza-Ramirez P., Vardulaki K. (2002). A description of an intermediate care service using routinely collected data. Journal of Nursing Management, 10 (4), 221-227. This study explores the information available from routine data sources to assess its potential for monitoring performance. Abstract available

(7) Beresford P., Carter T. (2000). Age and Change. Models of Involvement for Older People. Joseph Rowntree Foundation. This report offers practical guidance and ideas to increase the involvement of older people.

(8) Bernhaut J., Mackay K. (2002). Extended nursing roles in intermediate care: a cost benefit evaluation. Nursing Times, 98 (21), 37-39. This paper examines the effectiveness of extended nursing roles in a GP-admissions unit. Abstract available

(9) Boston N.K., Boynton P.M., Hood S. (2001). An inner city GP unit versus conventional care for elderly patients: Prospective comparison of health functioning, use of services and patient satisfaction. Family Practice, 18 (2), 141-148. This paper examines patient satisfaction with a GP Unit and the impact of this type of care on health and social service use. Abstract available

(10) Bull M.J., Hansen H.E., Gross C.R. (2000). Differences in family caregiver outcomes by their level of involvement in discharge planning. Applied Nursing Research, 13 (2), 76-82. This US study aims to determine whether the level of family caregiver involvement in discharge planning for an older person makes a difference in caregiver health, discharge planning satisfaction, perception of care continuity, and acceptance of the caregiving role. Abstract available

(11) Bull M.J., Hanson H.E., Gross C.R. (2000). A professional-patient partnership model of discharge planning with elders hospitalized with heart failure. Applied Nursing Research, 13 (1), 19-28. This US study examines the value and effect of a patient partnership model involving older people and their carers in discharge planning. Abstract available

(12) Bull M.J., Kane R.L. (1996). Gaps in discharge planning. Journal of Applied Gerontology, 15 (4), 486-500. This study examines barriers to effective discharge planning for older people.

(13) Bull M.J., Roberts J. (2001). Components of a proper hospital discharge for elders. Journal of Advanced Nursing, 35 (4), 571-581. This US study aims to identify the components of effective discharge planning for older people and factors that impede this planning. Abstract available A Critical Appraisal of this article is available

(14) Carpenter I., Gladman J.R.F., Parker S.G., Potter J. (2002). Clinical and research challenges of intermediate care. Age and Ageing, 31 (2), 97-100. This is a commentary on the issues and challenges involved in applying research evidence to intermediate care.

(15) Clegg A. (2003). Older South Asian patient and carer perceptions of culturally sensitive care in a community hospital setting. Journal of Clinical Nursing, 12 (2), 283-290. This study examines south Asian patient and carer views of service delivery in the UK with the purpose of informing the development of culturally sensitive services from a user/carer perspective. Abstract available A Critical Appraisal of this article is available

(16) Comptroller and Auditor General. (2003). Ensuring the Effective Discharge of Older Patients from NHS Acute Hospitals. Department of Health. This report examines the problems which lead to delayed discharge among older people

(17) Cornes M. (2004). Inside multi-disciplinary practice: challenges for single assessment. Journal of Integrated Care, 12 (1), 3-13. This article discusses issues relating to the provision of intermediate care by joint-working.

(18) Cornes M., Clough R. (2001). The Continuum of Care: older people's experiences of intermediate care. Education and Ageing, 16 (2), 179-202. This paper reports on older people's experiences of a local intermediate care scheme, and explores some of the barriers to the effective provision of care.

(19) Crawford M., Rutter D., Manley C., Weaver T., Bhui K., Fulop N. et al. (2002). Systematic review of involving patients in the planning and development of health care. British Medical Journal, 325 (7375), 1263-1267. This is a systematic review examining the effects of involving patients in the planning and development of health care. Full text available A Critical Appraisal of this article is available

(20) Cunliffe A.L., Gladman J.R.F., Husbands S.L., Miller P., Dewey M.E., Harwood R.H. (2004). Sooner and healthier: a randomised controlled trial and interview study of an early discharge rehabilitation service for older people. Age and Ageing, 33 (3), 246-252. This study evaluates an early discharge rehabilitation service for older people. Abstract available

(21) Department of Health. (2000). The NHS Plan: A Plan for Investment, A Plan for Reform. Department of Health. The NHS Plan outlines the vision of a health service designed around the patient.

(22) Department of Health. (2001). Intermediate Care. Health Service Circular(PDF). 2001/001/Local Authority Circular. Department of Health. This document provides full guidance on the definition of intermediate care and the responsibilities of professionals and statutory agencies.

(23) Department of Health. (2001). National Service Framework for Older People. Department of Health. The National Service Framework (NSF) for Older People was published on 27 March 2001. It sets new national standards and service models of care across health and social services for all older people, whether they live at home, in residential care or are being looked after in hospital.

(24) Department of Health. (2002). National Service Framework for Older People. Supporting Implementation. Intermediate Care: Moving Forward. Department of Health. This report reviews current developments and issues in intermediate care for older people.

(25) Department of Health. (1999). Caring About Carers. Department of Health. This is the government's national strategy document for carers.

(26) Glasby J. (2003). Hospital discharge: integrating health and social care. Abingdon, Radcliffe Medical Press. This book describes and reviews the policy and research literature relating to discharge planning in the UK.

(27) Glasby J. (2002). Acute concerns. Nursing Older People, 14 (7), 6. This article briefing describes the implications of the findings of the Health Committee report on patient discharge.

(28) Glasby J., Littlechild R., Pryce K. (2004). Show me the way to go home: a narrative review of the literature on delayed hospital discharge. British Journal of Social Work, 34, 1189-1197. This is a review of the literature on delayed hospital discharge and its implications for practice.

(29) Griffith J.C., Brosnan M., Lacey K., Keeling S., Wilkinson T.J. (2004). Family meetings - a qualitative exploration of improving care planning with older people and their families. Age and Ageing, 33 (6), 577-581. This New Zealand study explores the value of meetings between patients, family and health and social care staff, regarding patient discharge. Full text available

(30) Health and Social Care Joint Unit and Change Agents Team. (2003). Discharge from Hospital: Pathway, Process and Practice. Department of Health. This "good practice guidance" is designed to help health and social care professionals provide appropriate discharge planning and practice for older people.

(31) Henwood M. (1998). Ignored and Invisible. Carers' Experience of the NHS. London, Carers National Association. This is a survey of carers and their experiences of admission and discharge planning.

(32) Henwood M., Waddington E. (1996). Hospital discharge: short but sweet. Health Service Journal, 106 (5517), 24-25. This article summarises the findings of the evaluation of a Hospital from Home project.

(33) Hill M., MacGregor G. (2001). Health's Forgotten Partners? How carers are supported through hospital discharge. Carers UK. This is a survey of the policies on carers of 23 NHS Trusts in North West England.

(34) Holzhausen E. (2001). "You can take him home now". Carers' experiences of hospital discharge. Carers National Association. This document reports on a survey examining how carers are dealt with by services before, during and after the discharge of a patient.

(35) Huber D.L., McClelland E. (2003). Patient preferences and discharge planning transitions. Journal of Professional Nursing, 19 (4), 204-210. This US article investigates the importance of patient and family preferences and participation in discharge planning, and describes the piloting of an instrument to measure patient preferences for discharge planning. Abstract available

(36) Huby G., Stewart J., Tierney A., Rogers W. (2004). Planning older people's discharge from acute hospital care: linking risk management and patient participation in decision-making. Health Risk and Society, 6 (2), 115-132. This paper reports findings from a pilot qualitative study which aimed to develop a methodology to explore older patients' participation in discharge decision-making. A Critical Appraisal of this article is available

(37) Hudgell A., Gifford J., Lee L. (2004). Intermediate care in a primary care trust. Nursing Standard, 18 (11 February), 40-44. This article describes a service model of intermediate care in one primary care trust, outlining the processes and challenges encountered in establishing this multidisciplinary cross-agency initiative. Abstract available

(38) Jewell S. (1996). Elderly patients' participation in discharge decision making: 2. British Journal of Nursing, 5 (17), 1065-1071. This article is the second in a two-part series describing a study exploring patient participation in discharge decision making.

(39) Jewell S. (1996). Elderly patients' participation in discharge decision making: 1. British Journal of Nursing, 5 (15), 914-916, 929-932. This paper describes nurses' views of the participation of older patients in their discharge planning. A Critical Appraisal of this article is available

(40) Manthorpe J., Cornes M. (2004). Intermediate Care: Older people's involvement and experiences. Journal of Integrated Care, 12 (6), 43-48. This paper briefly summarises the findings of a study to evaluate the involvement of older users in intermediate care, and practitioners' perceptions of user involvement.

(41) Martin G.P., Peet S.M., Hewitt G.J., Parker H. (2004). Diversity in intermediate care. Health & Social Care in the Community, 12 (2), 150-154. This paper discusses the evolution of intermediate care (IC) and presents interim observations from a survey of providers in England being conducted as part of a national evaluation.

(42) Mountain G., Pighills A. (2003). Pre-discharge home visits with older people: time to review practice. Health & Social Care in the Community, 11 (2), 146-154. This paper reviews the available evidence to make a case for a reconsideration of the practice of undertaking pre-discharge home visits with frail older people. Abstract available

(43) Nancarrow S. (2004). Improving intermediate care: giving practitioners a voice. Journal of Integrated Care, 12 (1), 33-41. This paper presents the experiences and perspectives of practitioners involved in intermediate care.

(44) Negus J. (2004). Improving care of older people through intermediate services. Nursing Times, 100 (28), 34-36. This article reports on two initiatives to help older people and their carers who are receiving intermediate care.

(45) NHS Executive. (1999). Patient and Public Involvement in the New NHS. Department of Health. This document sets out the action which the NHS Executive is taking to make patient partnership central to its work, and what the Government expects the NHS and other bodies to do to make this partnership a reality.

(46) Nuffield Institute for Health. (2002). Exclusivity or Exclusion? Meeting Mental Health Needs in Intermediate Care(PDF). Nuffield Institute for Health. This report outlines key findings and suggestions from a programme of seminars and consultations attended by people involved in delivering intermediate care, especially to people with mental health needs.

(47) Parker G., Bhakta P., Katbamna S., Lovett C., Paisley S., Parker S. et al. (2000). Best place of care for older people after acute and during sub-acute illness: a systematic review. Journal of Health Services Research and Policy, 5 (3), 176-189. This systematic review aims to assess the evaluative research literature on the costs, quality and effectiveness of different locations of care for older patients. Abstract available

(48) Pawson R., Boaz A., Grayson L., Long A., Barnes C. (2003). Types and Quality of Knowledge in Social Care. Knowledge Review 3. Social Care Institute for Excellence (SCIE). This document analyses and defines the different types of knowledge and information which may inform social care research and practice.

(49) Pearson P., Proctor S., Wilcockson J., Allgar V. (2004). The process of hospital discharge for medical patients: a model. Journal of Advanced Nursing, 46 (5), 496-505. This study tracks the discharge process of 30 patients and reports on the successes and problems of the system. Abstract available

(50) Reed J., Clarke C. (1999). Nursing older people: constructing need and care. Nursing Inquiry, 6 (3), 208-215. This review discusses the need to address the issues of older patients at both a practice and policy level. Abstract available

(51) Roberts K. (2002). Exploring participation: older people on discharge from hospital. Journal of Advanced Nursing, 40 (4), 413-420. This paper reports on an empirical study concerning older patients' participation in health and social care, especially in discharge planning and immediate post-discharge care. Abstract available http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10795274&dopt=Abstract A Critical Appraisal of this article is available

(52) Roe B., Daly S., Shenton G., Lochhead Y. (2003). Development and evaluation of intermediate care. Journal of Clinical Nursing, 12 (3), 341-350. This article reports on an evaluation of an intermediate care service, and a subsequent workshop which discussed ways of improving the service. Abstract available

(53) Royal Commission on Long Term Care for the Elderly. (1999). With Respect to Old Age: Long-term Care - Rights and Responsibilities. TSO. This report was commissioned in order to examine the short and long term options for a sustainable system of funding of Long Term Care for elderly people, both in their own homes and in other settings.

(54) SCIE Research briefing 3. (2005). Aiding Communication with People with Dementia. Social Care Institute for Excellence (SCIE). This is a research and policy briefing describing ways in which communication may be improved with older people with dementia.

(55) Scottish Intercollegiate Guidelines Network. (2002). Management of Patients with Stroke. Rehabilitation, Prevention and Management of Complications, and Discharge Planning(PDF). SIGN. This national guideline aims to assist individual clinicians, primary care teams, hospital departments and hospitals to optimise their management of stroke patients.

(56) Shah P.N., Maly R.C., Frank J.C., Hirsch S.H., Reuben D.B. (1997). Managing geriatric syndromes: what geriatric assessment teams recommend, what primary care physicians implement, what patients adhere to. Journal of the American Geriatrics Society, 45 (4), 413-419. This US study evaluates the responses of primary care physicians and patients to recommendations from a community-based comprehensive geriatric assessment (CGA) program for the management of four target conditions: falls, depression, urinary incontinence, and functional impairment. Abstract available

(57) Shepperd S., Iliffe S. (2004). Hospital at home versus in-patient hospital care. Cochrane Library. The aim of this systematic review is to assess the effects of hospital at home compared with in-patient hospital care

(58) Sherrat C., Younger-Ross S. (2004). Out of sight out of mind. Community Care. This article describes intermediate care facilities for people with dementia and the barriers to provision, including difficulties with needs assessment. A template for intermediate services written by Devon Social Services and Dementia Voice is included.

(59) Steiner A., Walsh B., Pickering R., et al. (2001). Therapeutic nursing or unblocked beds? A randomised controlled trial of a post-acute intermediate care unit. British Medical Journal, 322 (7284), 453-460. This randomised controlled trial aims to compare post-acute intermediate care in an inpatient nurse-led unit with conventional post-acute care on general medical wards of an acute hospital, and to examine the model of care in a nurse-led unit. Full text available

(60) Stevenson I., Spencer L. (2002). Developing Intermediate Care: a guide for health and social services professionals(PDF). King's Fund. This guide considers definitions of and policy for intermediate care; summarises the research evidence relating to this system of care; and makes recommendations on how to develop a local intermediate care plan.

(61) Tutton E. (2005). Patient participation on a ward for frail older people. Journal of Advanced Nursing, 50 (2), 143-152. This study uses focus groups and interviews to explore those factors that encourge patient participation. Abstract available

(62) Unsworth J., Hardy L., Binks E. (2000). District nursing involvement in intermediate care. Journal of Community Nursing, 14 (3), 21-24. This article discusses the role of community nurses in the provision of intermediate care.

(63) Vaughan B., Lathlean J. (1999). Intermediate Care: Models in Practice (PDF). King's Fund. This document describes a range of current models for intermediate care.

(64) Wilson A., Parker H., Wynn A., Spiers N. (2003). Performance of hospital-at-home after a randomised controlled trial. Journal of Health Services Research and Policy, 8 (3), 160-164. This study compares the performance of an admission-avoidance hospital-at-home scheme one year after the end of a randomised trial with its performance during the trial. Abstract available

Smith P. (1998). Death and dying in a nursing home. Norwich, University of East Anglia.

This is a survey of residents' views of end of life care in a number of UK care homes.

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