title: Resource usage and outcomes in a facilitated discharge service in Christchurch, New Zealand.
abstract: OBJECTIVE
  To describe the type and level of support provided by a facilitated discharge team to frail older patients discharging from a 113-bed elderly rehabilitation hospital and the outcomes achieved.
  
  
  METHODS
  Prospective data detailing reasons for referral, services provided and retrospective data on outcomes, were obtained to 90 days post discharge on visits to new patients during 21/2/08 to 15/7/08.
  
  
  RESULTS
  Seventy-four patients (mean age 82, 58% female) were included. The mean duration of intervention was 19 days with the most common reasons for referral being poor mobility/falls risk, poor cognition, hygiene concerns. The average number of contacts was 6.5. Patients with the highest number of contacts were those referred with patient anxiety/low confidence (7.4), and family concern (8.4). The most common interventions were family contact and management of carer stress, liaison with medical staff. Unplanned readmission (within 90 days) occurred in 32% whereas 12% and 8% were in residential care or had died respectively.
  
  
  CONCLUSIONS
  Managing the transition from hospital to home for older people requires a large range of interventions, particularly in this highly selected group. Unplanned readmission occurred in a third of this very frail elderly group, yet only 12% needed residential care, suggesting the reasons for readmission could be resolved. Patient or family anxiety resulted in more follow-up visits to patients, and inpatient teams should be mindful of this when planning discharges.
authors.affiliation: Auckland City Hospital, Auckland, New Zealand. omenzies@xtra.co.nz
authors.forename: Oliver H
authors.initials: OH
authors.lastname: Menzies
authors.forename: H Carl
authors.initials: HC
authors.lastname: Hanger
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care / Q000458:organization & administration*; D005260:Female; D005500:Follow-Up Studies; D016330:Frail Elderly / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data*; D006699:Home Care Services / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D009520:New Zealand; D017063:Outcome Assessment, Health Care; D010351:Patient Discharge / Q000706:statistics & numerical data*; D011788:Quality of Life; D012189:Retrospective Studies