X3.8 Support after discharge

Follow-up at home after discharge from hospital may extend the continuum-of-care process begun within the acute envi­ronment and supported discharge programs are now well established.  Such programs are generally short term in nature and have clear criteria for which patients are suitable.  Compared to more traditional in-patient management, supported discharge programs are associated with shorter length of stay and lower 90-day mortality, with little difference in readmission rate (Kastelik 2012), confirming the safety of such an approach. Over the longer term, an integrated approach involving a discharge plan shared with the primary care team together with access to a case manager through a web-based call centre has been shown to reduce re-admissions for COPD exacerbations compared to usual care (Casas 2006) [evidence level II].

Although a systematic review of structured, planned, post-discharge support  found evidence for a reduction in readmissions at 30 days, the study was unable to identify a single intervention ‘package’ that could be recommended (Pedersen 2017). Notably, a study of supported self-management following discharge, which combined home visits to empower participants to manage their COPD independently and case management to facilitate prompt and appropriate access to care (not included in the above-mentioned systematic review), did not find any significant benefit on COPD admissions or death when compared to usual care (hazard ratio 1.05, 95% CI 0.08 to 1.38) (Bucknall 2012). Not only do many of these studies have different outcomes, but many  were conducted in Europe and their applicability to the Australasian setting is not known. Telephone follow-up may be a way of systematically extending support to patients and increasing their coping strategies at home, but the outcomes of this intervention have not been studied systematically.