With the implemenation of diagnosis-related groups in 1983 and their focus on curtailing hospital costs by limiting hospital stays, increased attention has been given to the process of discharge planning. Effective discharge planning can reduce both the length of hospital stays and subsequent readmissions (Andrews, 1986; Barker et al., 1985). In addition, the hospital's responsibility for patient costs beyond approved lengths of stay and its concomitant responsibility for ensuring that discharge dispositions are appropriate further contribute to the importance of discharge planning.
As hospitals compete for patients, satisfaction has become an outcome measure that acts as an important indicator of the quality of care (Wagner, 1988). Consequently, ensuring patient and family satisfaction with services has become a particular area of concern (Christensen & Inguanzo, 1989).
Research on satisfaction with discharge planning indicates that the factors affecting patient satisfaction differ from those affecting the satisfaction of their relatives (Proctor, Morrow-Howell, Albaz, & Weir, 1992). Patient satisfaction appears to be influenced by worries regarding physical functioning and support after discharge, whereas family satisfaction is more dependent on the discharge process itself, including the time spent with professionals, the involvement of the patient in the process, and the number of service options offered. The satisfaction of both patients and their relatives with the discharge plans is greater when the discharge is to home rather than to a nursing home.
Balancing the discharge needs and concerns of elderly patients with those of their families and the hospital is a major challenge to hospital social workers (Abramson, 1988; Abramson, Donnelly, King, & Mailick, 1993; Coulton, Dunkle, Goode, & MacKintosh, 1982). This task is further complicated when the older patient is cognitively impaired and the primary responsibility for discharge rests with the family.
Attending to the discharge needs of dementia patients is a primary concern of acute care hospitals. Although patients with cognitive impairment account for only 2.3 percent of hospitalized patients, they have the longest average length of stay of any patient group (U.S. Senate, Special Committee on Aging, 1989). The ramifications of these prolonged hospitalizations can be severe because hospitals must absorb the Costs for any additional days beyond those authorized by the prospective payment system (Binder & Robins, 1990; Weiler, Lubben, & Chi, 1991). A key factor contributing to these prolonged stays is that these patients are more likely than others to be discharged to nursing homes (Travis, Moore, & McAuley, 1991).
FACTORS ASSOCIATED WITH NURSING HOME PLACEMENT
Caregivers of dementia patients are more likely to place the patient in a nursing home if the caregivers are white, female, younger, and feel burdened by the patient (Colerick & George, 1986). Behavioral problems of the patient that upset family relationships and demand continual supervision can also act as precursors to institutional placement (Diemling & Bass, 1986). Havingprovided care for a shorter time, extreme forgetfulness of the patient, and the number of children in the home have also been identified as influential factors in the caregiver's decision to seek placement (Pruchno, Michaels, & Potashnik, 1990).
The stresses encountered by caregivers of dementia patients have been well documented and include chronic fatigue, anger, depression, frustration, isolation, an increase in the use of psychotropic drugs, changes in physical health, and financial strain (Birkel & Jones, 1989; Chenoweth & Spencer, 1986; Motenko, 1989). Although caregiver responses to patient symptoms and behaviors vary, agitation and disruptive behaviors are among the most stressful symptoms because they are unpredictable and …