Who cares for the carers at hospital discharge at the end of life? A qualitative study of current practice in discharge planning and the potential value of using The Carer Support Needs Assessment Tool (CSNAT) Approach

Family carers need to be supported in their central role of caring for patients at the end of life, but brief practical tools to assess their support needs have been missing. To address this gap, we developed a brief evidence-based Carer Support Needs Assessment Tool (CSNAT) suitable for everyday practice.

OBJECTIVES To determine the effect of integrating informal caregivers into discharge planning on post-discharge cost and resource utilization in the older adult population. DESIGN A systematic review and meta-analysis of randomized controlled trials that examine the effect of discharge planning with caregiver integration begun prior to patient discharge on healthcare cost and resource utilization outcomes. MEDLINE, EMBASE and the Cochrane Library databases were searched for all English language articles published between 1990 and April 2016. SETTING Hospital or skilled nursing facility. PARTICIPANTS Older adults with informal caregivers discharged to a community setting. MEASUREMENTS Readmission rates, length of and time to post-discharge rehospitalizations, costs of post-discharge care. RESULTS Of 10,715 abstracts identified, fifteen studies met the inclusion criteria. Eleven studies provided sufficient detail to calculate readmission rates for treatment and control. Compared to usual care, discharge planning interventions with caregiver integration were associated with a 25 percent reduction in readmissions at 90 days (Relative Risk [RR], .75 [95% CI, .62-.91]) and a 24 percent reduction in readmissions at 180 days (Relative Risk [RR], .76 [95% CI, .64–.90]). The majority of studies reported statistically significant reductions in time to readmission, length of rehospitalization, and costs of post-discharge care. CONCLUSION For older adult patients discharged to a community setting, the integration of caregivers into the discharge planning process, compared to non-systematic inclusion of caregivers, reduces the risk of hospital readmission.

Research indicates that fewer people are able to die at home than would wish to do so. Furthermore the ability to die at home is unequally distributed depending on patient characteristics. Unless factors associated with home deaths are identified and interventions are targeted accordingly, further general improvements in care support may only help those already at an advantage. This paper reviews research investigating the relation between patient characteristics and home deaths and considers whether these variables influence place of death because they are associated with differential access to services, focusing on access to palliative home care. Patients with informal carer support were both more likely to die at home and to access palliative home care. Provision of home care did not remove the dependence on informal carers in achieving home death, however. An important target in improving home death rates is therefore better support for informal carers overall. Older patients were both less likely to die at home and to access home care. Once in home care they no longer were less likely to die at home. Although age related needs require consideration, improved access to home care is therefore likely to increase home deaths for older people. Women were less likely to die at home than men, yet younger women may be more likely to access home care. There is some evidence to suggest that men were less efficient as carers, which may help explain why women were less likely to achieve home deaths, while making their referral to home care more likely. While home care may help redress the gender imbalance, men may also need to be encouraged and enabled to take on the carer role. Cancer patients in higher socioeconomic groups were both more likely to die at home and to access home care. Hence home deaths may increase by improving access for lower socioeconomic groups to the services available.