The CARS Study: Communicating About Readiness (for Discharge)

Specific Aims are to:

• Describe patterns of communication about discharge and collaboration among members of the health care team
• Conduct psychometric testing of 3 forms of the Readiness for Hospital Discharge Scale (RHDS - MD, RN, Patient)
• Describe relationships between care team communication, patient perceptions of quality of discharge preparation and perceived readiness for discharge, care team (RN and MD) assessments of discharge readiness, and post-discharge outcome ( post-discharge coping difficulty, Emergency Department (ED) use, and 30 day readmission.
• Determine the impact of an intervention with the inpatient care team to improve discharge preparation communication.

H1: Patient perceptions of discharge readiness, post-discharge coping difficulty, ED use and readmission will improve following a care team educational intervention about discharge preparation, compared to pre-intervention baseline measures.

H2: Care team members will report improved frequency and amount of discharge preparation communication following a care team educational intervention about discharge preparation, compared to pre-intervention baseline measures.

H3: RN-MD collaboration will increase following a care team educational intervention about discharge preparation, compared to pre-intervention baseline measures

Inclusion criteria

• inpatient care team members from 2 nursing units of an academic medical center: Attending physician, resident, medical students, mid-level providers, staff RNs, and case managers/discharge coordinators
• adult medical-surgical patients admitted the 2 nursing units who are at least 18 years of age, speak English, and discharged directly home

Exclusion criteria

• patient discharged home with hospice care
• patients not discharged directly home
• decisionally incapacitated patients