An ageing population with an increasing life expectancy has placed significant demand on the healthcare system across the developed world [1
]. Older adults are the main users of the acute healthcare system in Australia, with higher numbers of hospital admissions than any other age group [3
]. Rising healthcare costs, increased consumer choice and a focus on aging in place have further increased the demand on the healthcare system [4
]. Not surprisingly, older adults are the target of numerous health care policies as a means to reduce this impact on the healthcare system and to enhance outcomes for older adults [4
During hospital admissions, older adults are at significant risk of functional decline and are often discharged at a lower level of functional ability than they had upon admission [6
]. Functional decline may lead to an increased need for services, lower levels of autonomy, readmission to hospital, or nursing care facility admission [7
]. Discharge planning is considered the best way to support the older adult to return home to pre-hospital function [8
]. The purpose of discharge planning is to enable both the health professional and older adult to work together to plan their return home, identify any needs and organise support for after discharge [9
]. Successful discharge planning may also reduce hospital length of stay, readmission rates and, caregiver burden and enhance the coordination of services [8
]. Results from two systematic reviews identify that discharge planning across the hospital and community environments show positive effects [8
]. However these results are based on lesser quality studies and conclude that further large randomised trials are required to comprehensively establish this outcome [8
Occupational therapists are involved in discharge planning as they consider older adults’ abilities to independently and safely function within their own environment [11
]. Assessments of the older adult’s functional ability may occur either within the hospital setting and/or within the home environment, generally during a pre-discharge home assessment [12
]. Yet, a lack of research has resulted in varying practices by occupational therapists for discharge planning.
In-hospital consultations are commonly provided in countries such as America, where subsidised healthcare does not support occupational therapy home visiting [12
]. In-hospital consultations enable the therapist to make decisions regarding an older persons ability to carry out ADL and IADL’s within their home environment and decisions on assistive technology [12
]. However, in-hospital consultations can be problematic in obtaining a true reflection of an older person’s home environment and their ability to function within this environment.
Research indicates that home assessments enable a contextually relevant reflection of the older adult’s functional ability [13
]. In countries such as Australia and the United Kingdom, pre-discharge home assessments are part of standard practice for occupational therapists working in aged care [15
]. Despite being commonly provided, a survey of occupational therapy departments in Australia highlighted that assessments are not conducted consistently across departments [15
]. The decision to carry out a home assessment can be policy driven, influenced by staffing levels and reliant on the clinical background and expertise of the individual occupational therapist [11
]. As a result, inconsistencies in home assessment procedures exist and non-standardised evaluation of outcomes is typical [11
]. Results of research also suggested that post-discharge home assessments may enhance the discharge planning process [14
]. Whether or not hospital consultations and/or home assessments are included in part of discharge planning practice is dependent on results from high quality research.
Results of two feasibility trials [16
] indicate that a large randomised trial to determine the effectiveness of occupational therapy discharge planning is achievable. These and other studies [15
] support the necessity of evaluating cost effectiveness of occupational therapy discharge planning in addition to clinical effectiveness of home assessments in reducing functional difficulties. Through cost effectiveness analysis, decisions can be made as to whether a new intervention is effective and whether or not benefits are cost efficient compared to current practice [20
]. Since occupational therapy treatment focuses on increasing or maintaining independence, there is a potential for discharge planning to reduce healthcare costs, including readmission to hospital, decreased community health service use and delay nursing care facility admission.
Research must be conducted to identify the best practice for occupational therapy discharge planning and this should be evaluated for its effectiveness and cost effectiveness. The HOME intervention has been developed from recommendations in occupational therapy literature as a method of comprehensive discharge planning and now requires evaluation. The primary aim of this study is to determine the effectiveness of occupational therapy discharge planning in reducing functional difficulties. The primary hypotheses is that people who receive the HOME intervention will have (i) higher levels of functional independence three months after discharge then the control group and (ii) higher levels of participation and resumption of usual life activities compared to the control group.