Joining Education and Service in Exploring Discharge Needs

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Abstract
Continuity of care beyond the walls of the acute hospital setting has always been a major emphasis in nursing. There is concern that the care needs of older adults at the time of discharge have been increased by shortened hospital stays. Yet little is known about the specific and changing health care needs of older adults during the early days at home following discharge from acute care, particularly those who are discharged without community referrals. To learn more about the experiences of this population, the College of Nursing at the University of Southern Maine, in collaboration with the Nursing Service Department at Maine Medical Center, conducted a demonstration project. This project involved follow-up home visits to older adults who were discharged to their homes from an acute care setting.