Abstract
Background: Admission to hospital is an essential response for the patient, but it also represents a break from their usual daily routine and environment. Often patients remain in hospital after clinical discharge due to a lack of social support and continuity of care in the community. The Discharge Planning Team (DPT), consisting of doctors, nurses and social workers, aims to prepare and optimise the transition process of the patient from the hospital environment to the community, enabling a safe discharge and ensuring the necessary continuity of care. Approach: All patients admitted to the Department of Internal Medicine 2 are assessed using three scales during the first 48 to 72 hours of hospitalisation: The Clinical Frailty Scale, administered by physicians, which assesses the degree of individual vulnerability based on clinical judgement; The Functional Independence Measurement Scale, administered by nurses, which includes a functional assessment in the areas of personal care, mobility and social cognition; The Social Service Intervention Complexity Assessment Scale with Adults in Hospital Context, administered by social workers, which is an innovative tool in the context of assessing the social needs of hospitalised patients. Results: The activity of the DPT has led to increased interaction between the different professional groups in the assessment and referral of patients, the decentralisation of information input on the electronic platform of the Portuguese National Integrated Continuing Care Network (RNCCI) and the holding of weekly meetings between the DPT, the hospital bed and discharge management team, the department manager and other professionals involved in the patient discharge process. In 2023, 90.5% of patients admitted to Internal Medicine 2 were assessed by the DPT within the first 48-72 hours of admission and 243 were referred to the RNCCI. The DPT activities contributed to a reduction of 2 days (from 12.7 to 10.7 days) in the average length of stay per patient in the Internal Medicine 2 department. Implications: Discharge planning is interdisciplinary and has a pluralistic vision. DPT facilitates timely discharge, reduces inappropriate length of stay and promotes safe discharge from hospital. Efficient management of hospital bed occupancy increases installed capacity for acute patients and provides better access to healthcare. In the future, we hope to strengthen links and collaborate with primary care professionals to ensure appropriate and articulated transitions between different levels of care.