Providing patient-centered enhanced discharge planning and rural transition support: Verifying discharge orders during rural transitions

Patients typically leave a hospital with numerous tasks that need to be performed in order to complete their treatment successfully. The discharge process is designed, in part, to describe the services a patient needs to secure or the tasks they need to perform in order to complete treatment and promote recovery once he or she gets home. Many of the orders or services planned should be implemented immediately or soon after discharge to be useful. Some involve additional medical treatment. Others may involve starting long-term services that address chronic conditions. In this delicate transition, hospital staff may not convey the orders clearly or may not complete tasks. A patient preparing to leave the hospital may have limited time to follow the description or not be responsive to the staff. The patient may simply forget the information provided or misunderstand it. Written information may be difficult to read (e.g., small print, dense wording). Similarly, providers referenced in the plan may misunderstand, misinterpret, or simply forget. Accordingly, there is a need for methods to increase the likelihood that these orders are filled and needed treatments are completed. One approach is to monitor the implementation of these components of a discharge plan. This document is a brief practice guide outlining an early step in providing rural transition support, the verification of discharge orders

Providing patient-centered enhanced discharge planning and rural transition support: Conducting a rural transition needs assessment

Researchers have suggested that readmissions following hospital discharge might be reduced by providing additional resources to patients most likely to be re-hospitalized. They have suggested three broad approaches to assessing the likelihood of readmission and prioritizing patients for extra support. These approaches include: (1) medical risk, (2) personal capacity, and (3) environmental. While work on assessing medical risk and personal capacity has been reported, few researchers have explored the role of environmental factors. We used the third approach, an environmental perspective, to develop and test a Rural Transition Needs Assessment. This process involved patients in assessing their practical needs for recovery at home. Needs included several community factors that may affect a patient’s ability to achieve a smooth transition home. The environmental approach assesses a patient’s needs for community supports. A needs model may be somewhat less efficient than the other approaches because each individual’s needs must be assessed but it points neatly to solutions in the community. Further, it is less likely to provide services to those who do not need them or to miss providing service to those who do. Such an approach may complement and enhance standard risk and capacity assessments

Providing patient-centered enhanced discharge planning and rural transition support: Developing a local health and human services resource bank for rural communities

Patients may have a wide range of needs when they are discharged from a regional hospital back home to a small town or rural community. Discharge planners and other staff at the regional referral hospital are seldom aware of the range of services and resources that a patient could use to facilitate their recovery close to home. Indeed, in our research, regional providers acknowledged that they lacked information about the many small towns they served in their catchment area. Patients, regional referral hospital staff, and small town providers all reported that this frequently led regional providers to refer patients to services and providers in the city. Facilitating a smooth transition from a regional referral hospital back home to a small town or rural community requires that a patient be connected with as many local resources as possible to meet the needs they have. The purpose of this practice guide is to outline how service providers can develop their own health and human services resource bank and build a catalog of resources. A complimentary document describes how to load and program a tablet computer with a resource bank

Providing patient-centered enhanced discharge planning and rural transition support: Building a rural transitions network between regional referral and critical access hospitals

Residents of rural and frontier counties experience significant disparities in healthcare access and outcomes when compared to their urban counterparts. The organization of health care delivery contributes significantly to these disparities. Simply put, rural residents can face many challenges when they have to go to a hospital in a distant city for treatment and then return home to recover. The transition back home is also problematic because discharge planning generally does not adequately account for limited access to care in rural areas. The specific aim of this research project was to ascertain rural patients’ actual experience of the discharge planning process, and to involve patients and rural providers in designing and testing a contextually appropriate rural model that improves patient outcomes and reduces re-hospitalizations. This manual was used in a research project, Rural Options at Discharge – Model of Active Planning (ROADMAP). Our objective was to develop and evaluate a model that improved the likelihood of a positive recovery and reduced the likelihood of re-hospitalization. Current trends in health care delivery suggest that the right supports provided to patients at the right time may improve outcomes and reduce re-hospitalizations. For patients being discharged from a tertiary care facility back to a small town or rural community, this support includes assistance in addressing instrumental and social support needs. The methods included in this manual come from the literature, from cutting-edge practices in the field of care coordination, from recommendations of medical care providers, from patients themselves, and from lessons learned through this research process