Discharge planning for complex patients in Spain: the patient/family point of view and teamworking role

The healthcare system is designed to respond to acute care needs and it is an “inappropriate organization” for patients who do not suffer from acute illnesses. The care of chronically ill patients is complex for several reasons: involvement of multiple health professionals, exacerbations over time, presence of co-morbidities, social support needs, etc. The act of discharge is a vital element in continued care process for the patient and it is useful to synthesize all available information. The discharge plan must be prepared from the time of hospital admission and in complex cases a coordinator is required; the case manager. In Spain, there are no widespread-specific programs to improve the discharge process for complex patients. According to available resources and needs there are different programs: Pre-Alt program (to optimize the administrative circuits), liaison nurse, hospital at home, specialized support teams, integrated care services or technology-based discharge support. The optimization of the discharge process is closely related to the health professionals’ working way and teamwork is absolutely essential. Non-technical skills are essential for teamwork. The team must be incorporated values, such as the critical review of procedures, the acceptance of errors (and subsequent learning process), negotiation in cases of discrepancies, etc. Therefore, health organizations should seek out spaces (physical and temporal) so that inter-professional teams could deal with the emotional side of clinical practice (fears, losses, pain, distress and adversity) in order to achieve maximum professional efficiency and efficacy.