These readmissions crop up as a result of mistakes resulting from lack of proper care for the patients after discharge, or discontinuation of medication (DOH, 2005). Low health literacy being in high rates gives rise to increased rates of re-hospitalisation, especially, in urban patients, who earn low income. Lack of coordination between the in-patient and out-patient process, boosts the risk of readmission in hospitals, together with gaps in social care and supports. Primary care physicians find it hard to understand the complex process of hospitalisation, since the inpatient care is provided in the hospitals (Bortwick et al., 2009). A discharge plan is the key tool used by the primary care- providers so as to go on with the care of the patient. Therefore, a safe and comprehensive discharge plan is essential when discharging a patient, in order to aid the primary care providers and social workers in their duties.
A discharge plan
Discharge is a vital component of care management in any aspect. It makes sure that social care and health systems remain proactive when supporting patients, their families and carers, when there is the need to go home, or move to a different setting (SPLG, 2010). Mr. Sharma, 87 years old man has been hospitalized and, due to the considerable progress he has made in recovery, he will be discharged after ten days. A safe and comprehensive discharge plan needs to be developed which will suit him, and which will ensure his recovery without re-hospitalisation. Mr. Sharma’s discharge plan is supposed to prepare the home for him, to meet all his needs, reduce the probability of readmission, as well as saving on social care services (SPLG, 2010). Putting in mind that Mr. Sharma has multiple conditions, an open wound, he is taking many drugs, and that he is an old man, the following discharge plan will best suit him. A discharge plan will help his carers after he is discharged, to coordinate services and care (Katikireddi and Cloud, 2009). This paper will address the probable problems, the interventions, and the rationale behind the decisions made.
Problem The patient is an old man aged 87 years old. Outcome Being an old person, the patient requires careful and extra care since he is exceptionally delicate. Close supervision should be done always to ensure all the medical requirements are done (Lindenberg, 2010). Intervention 1. Meet with the family members and the carers of the patient, in order to discover who takes care of the patient most time, prior to discharge (Roberts, 2002). 2. Explain the need to have a person close to Mr. Sharma always, and close supervision. 3. Ensure that the patient will be kept busy and occupied. This can be through the provision of a television set or even constant company, to avoid boredom. 4. Discover if there is polypharmacy. Rationale The patient is an elderly person and hence the need to meet with the family members and the carers to enlighten them on the complications faced by old people after discharge, and the factors that can lead to readmission. According to the National Service Framework for older people, old people are likely to suffer multiple complications, unlike, young people. They can have different conditions requiring different and specific treatment (DOH, 2001). The need to meet with the family members and carers of the patient is to make them understand how to care for the old person to reduce the case of readmission. The elderly patient needs a person close to him to monitor

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