The Regional Discharge Model development project

PURPOSE/THEORY: The goal of the Regional Discharge Model (RDM) project was to develop discharge models, avoid unnecessary hospitalization, and improves the transfer of the patient to the right follow-on treatment or care, utilizing the public and private sector, research and training as well as developing technologies like the Regional Health Information Systems (RHIS) in the Satakunta Hospital District area. The RDM project is part of the ‘Whole life at home’ initiative funded and administered by the Satakunta Hospital District and supports the nationwide goals definition in the Finnish Ministry of Social Affairs and Health policy. METHODS: The method used was a descriptive statistics study. The questionnaire included both structural and open-ended questions. The target group was the immediate supervisors in primary health care and social services in the Satakunta Hospital District area (n=147, n=92). RESULTS AND CONCLUSIONS: There were many challenges in the discharge and follow-on treatment when transferring from special health care, such as a lack of planning with the receiving organizations and insufficient coordination between the various professionals involved. The flow of information was inadequate and often presented in paper or oral format, rarely transferred electronically. Integrated patient care was not always well managed in primary health care and social services in the hospital district. However, continuity of care was safeguarded and discharge proceeded safely, and professionals also valued the expertise of other organizations. Generally, the organizational climate was supportive to the discharge and encouragement of patients. DISCUSSION: With integrated patient care, the development of discharge models is the responsibility of both special health and primary health care and social services. This requires the commitment of the professionals and the organizations to the development work throughout the region.