1. Holland, Diane E. PhD, RN
  2. Mistiaen, Patriek PhD, RN
  3. Bowles, Kathryn H. PhD, RN, FAAN


Purpose of Study: The purpose of this study was to determine the extent to which patients discharged "home to self care" experienced problems and unmet needs. A secondary aim was to explore potential differences in problems and unmet needs between medical and surgical patients.


Primary Practice Setting: The study setting was acute care in 2 hospitals that were part of a large academic medical center in the Midwest.


Methodology and Sample: The prospective, cohort survey study was designed with a systematic sampling strategy to identify 130 cognitively intact adults hospitalized for either medical or surgical reasons who planned to return home after discharge without formal community services. The hospital information system was checked daily to verify whether dispositions were coded "home to self care," and to verify whether the patients were not seen by a discharge planner. The Problems After Discharge Questionnaire-English Version (PADQ-E) was then either mailed or administered via a phone interview approximately 1 week after discharge.


Results: Overall, 73.8% wanted more information about one or more topics related to their care. Most frequently mentioned were "when they would be completely recovered" (38.0%) and "where and how they could get nursing care at home if they needed it" (36.9%). A majority (91.8%) reported difficulties related to at least 1 physical complaint. Pain was most frequently mentioned by surgical patients (88.1%). Getting tired quickly was an issue for both surgical (76.2%) and medical patients (62.8%). More than 85% received help at home from family or friends. Surgical patients received significantly more assistance than medical patients with personal care, household activities, and mobility. Approximately 1 in 4 surgical patients reported an unmet need within the Physical Complaints subscale on the PADQ-E.


Implications for Case Management Practice: Potential problems that may occur after discharge have little chance of getting addressed if not identified during the discharge planning process. Standardized, early screening to accurately identify patients at risk for unmet needs after discharge is critical to the development and implementation of a quality discharge plan. The lack of time available to hospital clinicians to assemble and interpret extensive and complex information calls for improved methods to support identifying patients at risk for poor outcomes, engaging discharge planners efficiently and accurately, providing a standardized assessment to identify and address continuing care needs, and identifying patients who would benefit from post-acute care. Case managers advance their practice by advocating for and participating in the development of improved methods.