Nursing Research Paper on Discharge Planning and Post-Acute Care in Saudi Arabia

Discharge Planning and Post-Acute Care in Saudi Arabia

Introduction

            Health care systems across the world are facing a number of challenges, which include changing patterns of diseases, a shortage of health care professionals, inaccessibility of services, and insufficient resources. Given that an increasing population creates a greater demand for healthcare services, the shortage of hospital beds due to high admission rates and increased length of stay are some of the challenges that the healthcare system of Saudi Arabia is struggling to overcome. The Saudi Arabian government funds 244 hospitals that have a capacity of 33,277 beds (Almalki, Fitzgerald, & Clark, 2011). However, a forecast of bed capacity shows that, by 2013, the healthcare system in Saudi Arabia will require about 14,700 beds to meet the increasing demand for healthcare services (RNCOS, 2011). The shortage of beds implies that the healthcare system needs to formulate ways of increasing hospital bed capacity. The problem being investigated is the Saudi Arabian hospital bed shortage due to increased length of stay in hospitals by patients with chronic illnesses, the elderly, and the disabled. The purposes of the proposed study are to describe the post-acute care needs and also the need of effective discharge planning.

The government of Saudi Arabia has given the first two priorities to healthcare services and education. A huge part of the Saudi’s government budget goes to the Ministry of Health every year. Hence, the Ministry of Health has the responsibility to provide the best healthcare services to the population. The Saudi government has supported the healthcare systems at all levels: primary, secondary, and tertiary. Great healthcare services have been provided to the Saudis and non-Saudis during the past few decades. Therefore, people in Saudi Arabia have received wonderful healthcare services during that time (Almalki, Fitzgerald, & Clark, 2011).

Health Issues in Saudi Arabia

            In 2010, the Saudi population was 27.1 million compared with 22.6 million in 2004 (Central Department of Statistics and Information, Saudi Arabia, 2011). The United Nations estimated that the population will be 39.8 million by 2025, and it will be 54.7 million by 2050 (United Nations, 2003). Therefore, the demand of healthcare services will be increasing in the near future (Almalki, Fitzgerald, & Clark, 2011).

A shortage of beds in various healthcare centers in Saudi Arabia has reduced the accessibility of quality healthcare services, as healthcare providers are unable to admit some patients. According RNCOS (2011), by 2013, the health care system of Saudi Arabia will require an additional 14,700 beds to meet increasing demand for healthcare services. Although many factors contribute to the shortage of beds, length of stay in the hospital by patients is one that contributes significantly to bed shortage in Saudi Arabia. Longer length of stay reduces bed capacity. However, the need of post-acute care facilities and effective discharge planning are strategies that may reduce the length of stay, and thus improve bed capacity in a hospital. However, this has not been evaluated in Saudi Arabia. 

Additionally, effective discharge planning enhances safety of patients, because it guides the selection of post-acute care, which enhances recovery of patients. Healthcare systems in other countries recognize hospital discharge planning as a strategy for creating a seamless transition of care for discharged patients. Accrediting organizations, such as the Joint Commission and Center for Medicare & Medicaid Services, recommend the application of hospital discharge planning as an intervention to improve the quality of healthcare and patient outcomes (Masica, Richter, Convery, &Haydar, 2009).

The density of beds in hospitals varies from one country to another depending on the economic and social conditions of the people. Since the United States is a developed country, it has 30 hospital beds per 10,000 citizens (World Health Organization, 2013). Availability of effective discharge planning mechanisms in the United States has reduced average length of stay to less than 5 days (OCED, 2011). Comparatively, Saudi Arabia has a bed density of 22 hospital beds per 10,000 citizens (World Health Organization, 2013). Despite the low bed density, the average length of stay is about 8 days (Almoudi, Attar, Ghabrah, & Al-Qassimi, 2009).

Health care systems in the United States and most European countries provide post-acute care to the elderly patients or disabled patients who are unable to perform activities of daily living due to their illnesses or ages. In Saudi Arabia, the healthcare system provides minimal post-acute care. Normally, post-acute care in Saudi Arabia is for elderly people who are poor and do not have any family members to take care of them. Since the Saudi Arabian culture expects children to take care of their parents, most of the elderly people do not seek post-acute care. Conventionally, parents bring up their children by educating them so that the children can contribute to the society by taking care of the parents during old age.

Changing Disease Patterns

            Saudi Arabia is considered a developing country. However, it is developing rapidly and many people from outside Saudi Arabia are still coming to work in different jobs. Consequently, most of the Saudi’s people have started to change their life styles in terms of eating habits, transportation, etc. For example, they have shifted from good and healthy eating habits to a big demand on fast and fatty food. Moreover, more cars have been used as a result of economic development. This is a normal reaction for the developing countries. Therefore, more chronic diseases such as diabetes mellitus and hypertension have been diagnosed and are increasing. In addition, due to increasing transportation such as cars and trucks, and some factories, the contamination has increased. As a result, bronchial asthma is considered the third cause of hospitals’ admission (Almoudi, Attar, Ghabrah, & Al-Qassimi, 2009).

The occurrence of chronic conditions due to aging or diseases usually compels family members to seek management and treatment interventions from the nearest hospital. In this view, chronic conditions pose a significant burden to the hospital because patients stay for long periods in spite of the fact that hospitals have a low bed capacity. Additionally, despite the presence of preventive measures, there is an increase in the incidence of road accidents in Saudi Arabia. These road accidents have increased the demand for healthcare services, which subsequently lead to the shortage of beds in various hospitals. According to Al-Shehri and Abdel-Fatta (2007), most of the traumatic accidents cause quadriplegia (72.8%), which requires long-term treatment in the hospital. Thus, long-term treatment of patients causes congestion in the Saudi Arabian hospitals, which have limited bed capacity. Because there is limited post-acute care, there are few sites where patients can receive rehabilitative care outside the hospital. 

Saudi Arabian Health Care System

The health care system of Saudi Arabia is comprised of primary care levels (health centers), secondary care levels (general hospitals), and tertiary care levels (specialized hospitals). Specifically, in Saudi Arabia, there are some hospitals and primary healthcare centers operated and supported by the Ministry of Health that provide the treatment for free. On the other hand, there are some hospitals that are considered independent, but are supported by the government. Those hospitals belong to some other sectors or ministries such as military hospitals and National Guard hospitals. These hospitals provide the healthcare services for their employees and their families, and for anyone in crisis or emergency. Moreover, there are some private hospitals and medical centers operated and run in a business way so the patients have to pay. The ministry of Health has 244 hospitals with occupancy of 33,277 beds, and 2,037 primary health care centers. The independent hospitals include 39 hospitals with 10,822 beds. Finally, there are 125 private hospitals with 11,833 beds and 2,218 health clinics (Almalki, Fitzgerald, & Clark, 2011)

The healthcare system provides geriatric and related healthcare services to patients admitted to general hospital beds during their initial treatment. However, after undergoing treatment, healthcare providers find it difficult to discharge patients because cheap alternative facilities are limited while patient’s relatives are unwilling to provide care at home. Hence, the healthcare system then bears the burden of taking care of patients with nowhere else to go (e.g. elderly people).Masica, Richter, Convery, and Haydar (2009) state that healthcare systems should design effective programs that reduce the cost of care and improve the safety and quality of care. In this view, the health care system of Saudi Arabia should develop post-acute care facilities and effective discharge planning, which may reduce bed congestion and improve patient outcome during post-acute care.

Literature reviews

            A study was done through 2000-2005 to determine the most popular causes for hospitalization in Saudi Arabia. This study took place in one of the teaching hospitals in the western region of Saudi Arabia. The sample was 5,594 patients who had been admitted to the hospital. A whole review for patients’ medical files was done to know the main cause for admission as well as other diagnoses. Saudi patients represented in this study 44% of the sample, while the remaining 56% of the sample represented other nationalities. The first main cause for admission according to body systems was cardiovascular causes (19.9%), followed by respiratory system causes (14.5%), hematology (12.7%). The three top diagnosed diseases were diabetes mellitus, ischemic heart disease, and bronchial asthma. The main average age for admitted patients was 46-65 years. In addition, the average of the length of stay was calculated in this study; it was 8.3 ± 6.3 days (Almoudi, Attar, Ghabrah, & Al-Qassimi, 2009).

            Another study was done in a rehabilitation center in Saudi Arabia to discover which kind of disability the patients who have been admitted had. This center had 100 beds and was a part of the Armed Force Hospital in Taif, Saudi Arabia. A lot of referrals were forwarded to this center from different regions in Saudi Arabia. The researchers reviewed 850 patients’ files from 1999 through 2005 to achieve their goals. Males composed 68.6% of the sample, while 31.4% were female, and all of them were Saudis. Quadriplegic patients comprised 21.7%, paraplegic comprised 14.4%, hemiplegic comprised 39.2%, and 24.6% had other disabilities such as abnormal speech, and amputation. In this study, the hospitalization stays varied: 26% were for less than one month, 68.6% were for 1-12 months, 1.5% were for 1-2 years, and 4% were for more than 5 years. Disabilities caused by road traffic accidentsconstituted 36.6% of patients in this study. This rehabilitation center accepted only referrals from the Armed Force Hospitals in Saudi Arabia. Thus, it is only for military people and their families (Al-Shehri, & Abdel-Fatta, 2007).  

In fact, there are six long-term hospitals in Saudi Arabia. The first one was built in 1987. They are distributed throughout Saudi Arabia, and they have 476 beds in total. In 1994, a cross-sectional study was done to determine the type of patients these hospitals had admitted. Researchers began by filling out datasheets about patients’ information. They also conducted interviews with healthcare providers, and patients and their families. The total patients were 372 patients. The average hospitalization period was about 75 weeks. Males represented about 61% of the sample, while 52.7% of the sample were 60 years or older. Male patients who were 45 years or younger represented about 52.6% of all male patients. This is because of the road traffic accidents. Only 8.9% of patients had some progress in their treatment. Sixty-eight percent represented bedridden patients, while 19.1% had some mobility. Fifty-seven percent needed constant care and attention by nurses. Some patients (45%) preferred to stay in the hospital for different reasons. In addition, 67.5% of patients’ families refused to discharge their patients for different reasons. Elderly patients represented a high percentage in this study. There are some expectations that the number of old people is increasing. Due to life-style changes in Saudi Arabia and some other factors, such as increasing the number of working women, the health care needs for older people and long-term patients will be a big issue. There were about 24% of patients who had no visits from their families; of course, this is one of the modern life disadvantages (Al-Shammari, Jarallah, &Felimban, 1997). The problem here is that there are too many different cases in one facility. This means, these long-term hospitals were filled with all kinds of patients. They accepted elderly patients, and disabled patients who needed some rehabilitation. There is a need to re-evaluate the situation and specify a qualified facility, such as a nursing home, to take care of elderly patients and the disabled.

The recent emphasis on enhancing the post-acute is being driven through an interest of reducing hospital readmissions. In the United States, there is 18 percent rate in hospital readmissions within a period of 30 days of discharge; furthermore, 76 percent of these hospital readmissions are preventable. According to the data from Medicare, about half of the readmitted patients do not receive a follow-up or care in the period 30 days after hospitalization. Those patients who do not receive care after staying in hospital usually encounter care, which is fragmented as well as uncoordinated. This leads to duplication services, unsuitable and high levels costs of healthcare, patients stress, and medication errors.

Recent studies done by Coleman et al (2006) suggested that interventions targeted towards the post acute care may reduce hospital readmissions by almost one-third of the rates. These interventions often focus on issues of promoting the level of healthcare transition process, enhancing self-management capacities, and increasing the accessibility of the required tools and information in hospitals. In the United States, transitions interventions a well as transitional care models are the two terms that are frequently used in order to refer to the improvement interventions, which emphasis of the post-acute changes. For instance, the guided care, care for elders, and geriatric resources mark the coordinated care models, which have care transition elements in the United States.

Reducing the rate of hospital readmissions has become a priority in the United States in the recent years. It has been prioritized by a number of policymakers as well as other players, who seek to enhance health care costs and quality. Researchers have estimated that the national fiscal effects to Medicare due to unplanned readmissions stood at $17.4 billion in the year 2004. The rate of hospital re-hospitalization in the United States seems to increase the peril of health problems, thus, leading to greater functional as well as cognitive issues for patients. In the years 2009, the Medicare payment Advisory suggested that a large rate of re-hospitalization can be potentially prevented and is highly recommended for enhancing the quality of post-acute transition process in the country. The recommended improvements included better communications as well as a more coordinated care, which should occur before as well as after the discharge of patients.

Furthermore, recent research on the issues of care transitions has also established a very strong evidence for the many types of interventions. A randomized and controlled evaluation of care transitions depicted that intervention subjects had reduced re-hospitalization levels at 30 days as well as 90 days when compared to the control subjects. The intervention group had mean of hospital costs, which lower considerably lower as compared to those of the control group. A separate evaluation also established that intervention patients had a lower rate of re-hospitalization as well as hospital costs as compared to the control participants (Medicare Payment Advisory Commission, 2006).

Discharging patients from hospitals marks a difficult and complex process, which is fought with many challenges. Ensuring that the rate of preventable re-hospitalization rates significantly reduced or prevented has the potential of greatly enhancing the quality of the lives of patients as well as the financial well-being of many of the healthcare systems. There were more than 39 million hospital discharges in the United States in the year 2006. Among the Medicare patients, about 20 percent of the patients who are discharged from hospitals are eventually readmitted within a period of 30 days. The rate of unplanned re-hospitalization in the United States, which stood at a cost of 17.4 billion, contributed to approximately 17 percent of the total hospital payments from Medicare in the year 2004 (Davies et al, 2004).

Whilst the accurate number of preventable readmissions is not exactly known, a systematic evaluation of about 34 studies, which were mostly based on the retrospective review, established that between 5 percent and 79 percent of hospital re-hospitalization were likely to be avoided. Reducing the level of readmissions in the United States has been a major target and a priority in the United State health care reforms (United States, 2006). In the year 2012, the government of United States embarked on penalizing hospitals for issues of excess readmissions, which initially involved to about 1 percent of the total payments from Medicare. Roughly, two-thirds of the United States hospitals experienced this penalty under this particular program in the period 2012. These penalties are expected to increase to approximately 3 percent of the total health care reimbursement in the year 2015 (Medicare Payment Advisory Commission, 2006).

Moreover, the effect of discharge planning on the outcomes in the United States seems to be very limited. A systematic review in the year 2010 realized a profound patient satisfaction as well as small diseases in the length of hospitalization and readmission rates with discharge planning, whereas the mortality rates remained unchanged. Another study that studies discharge planning for many of the patients with heart failure found no relationship among the rate of readmissions as well as chart-based measure. Only a very small relationship was noted for the lower readmission rates with highest (Becker & Whyte, 2006).

Discussion

            It is true that many of the health care systems around the globe are facing major challenges, including include changing patterns of diseases, scarcity of health care professionals, lack of accessibility to services, as well as  scarcity in terms of  resources. Provided the fact that an increasing population establishes a greater demand for healthcare services, shortages in terms of hospital beds, which is attributed to high admission rates as well as increased length of hospitalization makes some of the challenges that the healthcare s in Saudi Arabia are under pressure to conquer.

The government of Saudi Arabian funds a total of approximately 244 hospitals with a capacity of 33,277 beds. However, an estimation of bed capacity indicates that, by the 2013, the healthcare system in the country would require approximately 14,700 beds in order to meet the increased demands for healthcare services. The lack of beds in Saudi Arabia suggests that the healthcare system needs to devise methods for increasing hospital bed capacity (RNCOS, 2011).

The Saudi Arabian government has provided the first two priorities to healthcare services as well as education. A large part of the Saudi’s government budget is allocated to the Ministry of Health each year. Therefore, the Ministry of Health bears the mandate as well as the responsibility of providing the best healthcare services to the people of Saudi Arabia. The Saudi Arabian government has previously supported the enhancement of healthcare systems at all levels, including the primary, secondary, and tertiary levels in order to ensure accessibility of these services to every citizen. In addition, many healthcare services have been given to both the Saudis and non-Saudis people in the previous years. This implies to the idea that the people in Saudi Arabia have received excellent as well as amazing healthcare services overtime time. However, the challenges that are prevalent and which have been documented over the time need to be pursued in order to ensure better healthcare services for all the people (Medicare Payment Advisory Commission, 2006).

As compared to other countries such as the United States as well as Europe, a health care system in Saudi Arabia is substantially low. In both the United States and most European, elderly people are provided with post-acute care. In addition, post-acute care is also offered to the disabled patients who are not able to perform a number of activities in their daily lives as a result of illnesses or age. Comparatively, in Saudi Arabia, the healthcare system offers minimal post-acute care to these groups of individuals. More often, post-acute care in Saudi Arabia is meant for the elderly people who are poor as well as those who do not have family members to take care of them (Gruber, 2011).

Furthermore, the issues of hospital re-admissions and discharge issues are very high in the republic of Saudi Arabia. The nation of Saudi Arabia lacks a comprehensive discharge plan as compared with nations such as the United States and Europe.  Hospital re-admissions in the nations of Saudi Arabia has contributed to reduced healthcare services as many people are readmitted back to the hospitals based on a variety of issues, including negligence by family members. The Saudi Arabian population is projected by increase tremendously and if necessary steps would not be ensured, then the problem will tend to escalate (Andersen, Rice, & Kominski, 1996).

Even though America also experiences a number of issues in its health care system, the problems are not extensive. United States had a well spelt discharge plan that ensures that the hospitals are well able to cater for other patients. The government of America has even gone further to penalize many of the hospitals that encourage excess readmissions. Moreover, the issue of post care in the United States is well catered for. There exist well post-acute transition programs and many of the nursing homes have played key roles in the United States. In effect, the nation of Saudi Arabia needs to have such programs in place in order to effectively manage the overwhelming numbers of patients seeking for health care services within the country. The governments of Saudi Arabia need to implement well spelt out discharge plans as well as ensure that appropriate policies are adequately adopted (United States, 2006).

Conclusion

            The government of Saudi Arabia faces major challenges in its approach to the issues surrounding the national health care system. Rates of readmissions in into the hospitals have increased the rate of hospital stay within the country. Moreover, faced with limited number of beds and rapidly increasing demand for health care services, the government of Saudi Arabia needs to adopt appropriate measures. Among these measures, there is high need for the adoption of a comprehensive discharge plan in order to decrease the rates of hospital stay. 

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