Delivery of home care services after discharge: what really happens.

Social workers in hospitals develop discharge plans for in-home patient care with little systematic feedback about postdischarge implementation. A telephone follow-up study of patients discharged from an urban teaching hospital in 1990 was undertaken to determine the extent to which discharge plans for home services were carried out and to identify factors associated with unsuccessful implementation. Overall, 72 percent of the patients received all, 19 percent some, and 9 percent none of the planned home care services. Great variability was found in service delivery: Registered nurse visits were the most successfully delivered type of service; 24-hour companions were the least successfully delivered service. Further, over one-third of patients experienced termination or reduction of services between discharge and the follow-up interview 21 to 28 days after discharge. Such unexpected and varied outcomes suggest the need for development of discharge follow-up programs that move beyond hospital walls to ensure that patients receive needed services.