Intervention
Subjects in the experimental group received routine hospitaldischarge
services, consisting of in-hospital health education
and occasional discharge referrals and the intervention
programme, consisting of both in-hospital and posthospital
components (Table 1). For routine hospital-discharge services,
the primary nurse provides standard health education,
which might not be based on a systematic assessment of the
caregiver’s individual needs or the home caregiving conditions.
In these routine discharge services, health education
and consultation seldom consider the family caregiver’s
competing needs after discharge. For routine discharge
referrals, the primary nurse or attending physician usually
refers a patient to the discharge-planning team if the patient’s
hospital stay is too long or he/she is having difficulties with
discharge. This team often makes referrals when a patient
needs skilled home nursing service or nursing home
placement.
On the other hand, the discharge-planning programme
developed in this study included both individualised inpatient
health education, referral services and consultations, as well
as postdischarge telephone follow-ups and home visits. In
addition to the routine hospital-discharge services, this