Usual care
The usual care was provided equally to all patients in the intervention and control group, thus all patients receive the same level of standard care. At Horsens Regional Hospital, planning of the discharge begins no later than the second day after hospital admission. Overall, the nurses are responsible for the daily assessments of functionality and needs and for care plans and digital communication with the home care staff and practical matters in relation to the discharge. On admission day, a medication reconciliation is conducted by a hospital doctor, and a nurse begins the nursing discharge status document and checklist.A nursing care plan is started the day after admission and digitally sent to the home care staff as a preliminary plan. This plan includes information about the expected discharge date, functional ability, need for home healthcare services after discharge and coordination in relation to the discharge. Families or other caregivers are only automatically involved in the plan if the patients explicitly want them to be involved in complex discharge situations. During admission, nurses assess and act on the need for assistive technology after discharge and the need for post-discharge follow-up from outpatient clinics, GPs, home care services, district dieticians and specialised services for specific patient groups.The nurse sends the updated nursing care plan to home healthcare before 12 p.m. the day before discharge. On the day of discharge, plans and lists are updated, the hospital doctor draws up a medication reconciliation, and prescriptions are written. If specialised care or treatment is needed, the nurse contacts the district nurse by phone as a supplement to the digital plan.Finally, the hospital doctor writes a discharge letter and digitally send it to the patient’s GP and district nurse. After discharge, the GP and district nurse are responsible for treatment and care. Online Resource 1 illustrates the components of the intervention and usual care.