Elizabeth Ahsberg
National Board of Health and Welfare, Sweden
Title: Discharge from hospital: A survey of transition to outpatient care
Biography
Biography: Elizabeth Ahsberg
Abstract
Introduction: Despite a generally decreased mean time for hospital care in Sweden, an increasing length of stay has been
highlighted among patients with long term care need.
Aim: Identifying challenges and potentials in the transition of patients between hospitals and primary care.
Method: Data of discharged patients were extracted from national registers and interviews were conducted with local
authorities in a sample of nine out of 21 counties, and a systematic literature search was performed.
Results: A total of 11, 21, 823 persons were discharged from Swedish hospitals in 2014. Of all discharged patients 3, 34, 420
had further need of medical care and 2, 21, 221 had further need of social care. Among these, 53,763 patients needed both
medical and social care. Of these, frail persons (primarily females 80 years or older) were 48%, who were readmitted to the
hospital within 30 days. The main reported difficulties were: a decreasing number of beds in hospitals and nursing homes,
lack of staff with proper education, problems in transfer of information between caregivers. Reported examples of adapted
working methods initiated to promote a coherent health care were, local follow-up of patient data and focus on cooperation
between caregivers, extensive initial home care after discharge, and outpatient care organized by both municipalities and
county councils. The scientific literature showed contradictory results about the effects of single interventions at discharge.
However, the number of readmissions to hospital may be reduced by combining several interventions before discharge and
follow-up after discharge. No consistent effects on patients' perceived quality of life, well-being or satisfaction were reported.
Conclusion: As many frail patients are readmitted to hospitals, primary care may need new working methods. In addition,
a new regulation on care coordinator for patients with extensive health care needs is introduced in 2018, which may help
increase patient safety.