I. Background
The problem of discharging patients from hospital have been well documented in the literature over the last 20 years. They included poor communication between hospital and community, inadequate notice of discharge, over-reliance on informal support and lack of statutory support, inattention to patients needs before leaving hospital, and wasted or duplicated visits by community nurses. Most patients discharged from hospital are able to return home with little or no support, while others will require a "package of care" to support them back to good health. Patient with complex care needs, including the frail elderly and those with mental health problems, may require continuing care in special housing, residential, or nursing homes. With this population, effective discharge arrangement is needed and the study on this problem is urgent in Korea because the Medical Reform Project is on suspension of success.
II. Results of the Study:
1. Discharge service needs assessed on 360 elderly patients who were hospitalized during the survey period at four university hospitals. Patients want to know the information on disease management after discharge. Follow-up telephone service is the most frequently checked service.
2. Multidisciplinary Discharge Planning is recommended at the hospital level to reduce the readmission and decrease the length of stay.
3. Further research is needed to validate and test the assumption of the solution which is developed in this research.
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