Rural Options At Discharge Model of Active Planning
Phase: NA
Conditions: All Causes Hospital Admissions
Sponsor: University of Montana

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Rural Options at Discharge Model of Active Planning (ROADMAP): 
Protocol and Statistical Analysis Plan 
 
 
 

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Methods 
Settings 
This study was conducted in Montana, a state with a population of 989,417 people living 
on 145,546 square miles for an average density of 6.8 persons per square mile.  St. Patrick 
Hospital (SPH) was the central site for this study.  SPH, a member of the Providence Health and 
Services System, is a regional referral hospital (RRH) serving Western Montana and Eastern 
Idaho.  SPH is located in Missoula, Montana, a city of 66,768 in a county of 109,299 people.  
SPH uses the Epic® electronic medical record system.  This study focused on patients discharged 
from the RRH to one of four Montana counties served by critical access hospitals (CAH) that 
also used the Epic® electronic medical records system, including Beaverhead, Lake, Powell, and 
Sanders Counties.   
The Montana Department of Public Health and Human Services designated all four of 
the counties involved in this study as rural counties (counties with less than 50 people per 
square mile).  Furthermore, all four were non-metropolitan counties and three of the counties 
met the criteria of being a frontier county (population of less than 6 people per square mile).  
Travel time to Missoula from the principal town of the four counties ranged from 79 (76 miles) 
to 145 (172 miles) minutes.  Portions of Lake and Sanders Counties are included in the Flathead 
Reservation, which is home to the Salish, Pend d’Oreille and Kootenai Tribes.  Table 1 provides 
basic demographic data from the most recent U.S. Census for each of the four counties 
included in the present study.  
 
 
 
 
 
 
 
 
 

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Table 1 
Characteristics of Geographic Area 
County 
Beaverhead 
Powell 
Lake 
Sanders 
Land Area (sq. miles) 
5,541 
2,326 
1,490  
2,760 
Population 
9,246 
7,027 
28,746 
11,413 
Density/Sq. Mile 
1.7  
3.0 
19.3 
4.1  
White 
94.9% 
92.4% 
68.2% 
92.1%  
Native American 
1.8% 
4.6% 
23.4% 
4.3% 
Hispanic or Latino 
3.7% 
2.3% 
4.0% 
2.6% 
Households 
4,110 
2,411 
11,829 
5,149 
Mean Number in 
Household  
2.11 
2.31 
2.38 
2.17 
Median Household 
Income 
$41,614 
$40,802 
$38,019 
$32.881 
Per Capita Income 
22,872 
$19,736 
$21,521 
$19,188 
Percent  Below Poverty 
15.1% 
15.3% 
22.4% 
22.0 
Principal City Population  
4,134 
3,111 
4,488 
1,313 
 
 
  Patient Population 
All patients from these four selected counties admitted to SPH for treatment and at 
least one overnight stay during the period of October 19, 2015 through November 30, 2016 
were eligible.  Patients were included if they were being discharged home or to a swing-bed 
arrangement in their home county critical access hospital.  Researchers excluded patients, if 
they were younger than 18 years old or older than 75 years old, were prisoners of the State 
correctional facility in Powell County, came from or were being discharged to a nursing home or 
other long-term care facility, were admitted with a primary diagnosis of a psychiatric 
impairment or substance abuse, were actively dying, or presented cognitive impairments that 
would significantly limit their ability to consent or to complete the measurement instruments 
(Flesch-Kincaid Reading Level = 7.5).   Figure 1 presents a patient flow diagram.   

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Figure 1:  Patient flow diagram of the ROADMAP study.   
Enrollment.  A Research Transitions Coordinator (RTC) received a daily report of patients 
admitted into SPH.  She reviewed the report to identify eligible patients.  Based on the review, 
she developed a list of eligible patients.  She then reviewed the list to identify patients who met 
any of the exclusion criterial; this produced a list of patient who met inclusion criteria to recruit 
into the study.  Next, the RTC went to each patient’s room to explain the study, to identify any 
additional factors that might exclude the patient, and to determine a patient’s willingness to 
participate.  If a patient met inclusion criteria and expressed interest, the RTC reviewed the 
informed consent material and enrolled the patient.   
The RTCs screened 751 patients from the four counties.  Of those, 570 patients were 
excluded as ineligible based on exclusion criteria, 54 who met the inclusion criteria declined to 
participate in the study, and 127 enrolled in the study.  Table 2 presents demographic 
information of participants by experimental condition as required by ClinicalTrials.Gov.   
 
 
 

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Table 2 
Demographic Characteristics of Study Sample Required for Clinical Trials 
 
Baseline A 
Intervention 
Baseline B 
Totals 
Enrolled 
63 
50 
14 
127 
Completed  
62 
47 
13 
122 
Lost to Follow-up 
1 
3 
1 
5 
Under 18 Years of Age 
0 
0 
0 
0 
Between 18 and 65 
37 
26 
10 
73 
Over 65 
26 
24 
4 
54 
Female 
28 
21 
6 
55 
Male 
35 
29 
8 
72 
American Indian, 
Alaskan 
5 
6 
2 
13 
Asian 
0 
0 
0 
0 
Hawaiian or Islander 
1 
0 
0 
1 
Black or African 
American 
0 
0 
0 
0 
White 
56 
43 
11 
110 
More than one race 
0 
0 
0 
0 
Unknown or Not 
Reported 
1 
1 
1 
3 
Subtotal 
63 
50 
14 
127 
Hispanic or Latino 
0 
0 
0 
0 
Not Hispanic or Latino 
61 
47 
11 
119 
Unknown or Not 
Reported 
2 
3 
3 
8 
Subtotal 
63 
50 
14 
127 
 

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In addition, Table 3 presents the number of patients excluded by criterion and Table 4 
shows the number of patient enrolled in the study from each county by experimental condition. 
 
 
 
 
 
 
 
 
Table 3 
Number of Patients Excluded by Criteria 
Exclusion Criteria 
Number of 
Patients 
Age 
242 
Not an Inpatient 
41 
Substance Abuse – Mental 
Illness 
65 
Prisoner 
29 
Extended Care Facility 
12 
Not Going Home 
26 
Extended Observation  
28 
Cognitive Impairment  
24 
Actively Dying 
16 
Other 
65 
Total  
570 

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  Table 4 
Participants by County 
 
Baseline Intervention Baseline 
Total 
Sanders 
10 
21 
4 
35 
Beaverhead 
8 
8 
0 
16 
Powell 
11 
6 
2 
19 
Lake 
34 
15 
8 
57 
Total 
63 
50 
14 
127 
 
 
Procedures 
SPH’s established discharge planning procedures and practices served as the standard 
comparator.  From the patient’s perspective, this involved three elements, including verification 
of financial means, discharge planning, and patient instructions.  Generally, patients who lacked 
health insurance or other means for paying medical and hospital costs were “flagged” at 
admission.  This alerted the Medical Assistance Program (MAP).  Staff from MAP went to the 
patient’s room to discuss options and outline a plan for payment.  For example, a MAP staff 
member might work with a patient to enroll in Medicaid so that his or her costs might be 
covered.  Six Discharge Planners (DP) served patients in the hospital.  When a Discharge Planner 
initiated work with a patient, she reviewed the patient’s file to determine what treatment the 
patient was to receive and examined any history that may be relevant to recovery.  Next, the 
DP typically visited the patient in the hospital room to assess the patient's situation.  This 
included determining if the patient had a place to go after treatment (e.g., home, shelter, etc.)  
and if they had someone to provide transportation there when discharged.  Depending on the 
patient's situation, the DP might consult with the patient's physicians, nurses, or other care 
providers, and might work to arrange transportation or temporary shelter. The DP entered 
findings and actions into the patient’s EPIC file.  Finally, treatment staff used information in 
EPIC to prepare an After Visit Summary (AVS) for the patient that included a description of the 
patient’s treatment, a list of medications and instructions for their use, and patient educational 

  CT.G ROADMAP 8 
 
materials about the treatment and self-care.  Depending on the patient’s condition and 
treatment, the AVS might include a follow-up referral (and sometimes a scheduled 
appointment for the patient).  Finally, the AVS was given to the patient when they left the 
hospital.  All patients enrolled in the study received these standard services. 
Enhanced discharge and rural transition planning.  Researchers engaged patients and 
other stakeholders in a structured process of contextual assessment and innovation to develop 
an Enhanced Discharge and Rural Transition model, protocol, and procedures (separate 
manuscript that can be cited).  Figure 2 outlines the components of both the standard practice 
and the enhanced model.  Researchers added 11 components to the standard practices, 
including: a Rural Transitions Needs Assessment, a resource bank for each rural community 
linked to categories of the needs assessment, a Patient Transition Agenda, an electronic 
episode of care in Epic® to support patient transition, patient-centered communication 
procedures between SPH staff and Local Community Transition Coordinators (LCTC), a 
discharge orders verification procedure, a transitions planning protocol, transitions follow-up 
procedures, a long-range goals assessment also linked to community resources, communication 
procedures to alert the patient’s PCP of their hospitalization and transition home, and a 
coordination mechanism between LCTCs at the CAHs and the Research Discharge Coordinators 
at the RRH to facilitate teamwork.    

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Figure 2:  Tentative model describing the Enhanced Discharge and Rural Transitions Process.  
The shaded boxes at the top of the figure represent the standard practice.  The open boxes at 
the bottom represent the experimental procedures.  All patients received the standard 
procedures.  Patients in the experimental conditions also received the enhanced procedures.   
In general, the enhanced model was based on the existing discharge planning protocol 
but extended it by creating new roles and functions that focused on addressing patient needs 
that might interfere with recovery at home.  Procedurally, a Research Transitions Coordinator 
located at the regional referral hospital used a tablet computer to conduct a Rural Transitions 
Needs Assessment with a patient.  The patient’s identified needs were linked to services and 
supports listed in a Community Resource Bank.  Together, these formed a patient’s Transition 
Agenda.  The RTC posted the Agenda in an Episode of Care (EOC) tab in Epic®.  
The RTC then notified the LCTC in the patient’s home community that SPH had admitted 
and was treating a patient from their community.  The LCTC reviewed the Transition Agenda 
and prepared for the patient's return to the community.  Once home, the LCTC contacted the 
patient to check on his or her status, and to work with the patient to develop and execute a 
Rural Transition Plan.   

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Needs Assessment and patient transitions agenda.  The RTC reviewed the Epic® medical 
record for patients meeting inclusion criteria to familiarize herself with the patient’s situation 
before visiting them in their room.  For patients in the intervention condition, once a patient 
was enrolled in the study, the RTC worked with the patient (and caregivers as deemed 
appropriate by the patient) to complete a structured Rural Transitions Needs Assessment using 
an electronic tablet to rate his or her confidence in their ability to meet each of 18 transition 
needs (e.g., housing, groceries and meals, medications, self-care, etc.).  The RTC read an item 
from a tablet computer screen and asked the patient to rate it.  Then the RTC recorded the 
patient’s rating by checking the relevant box.  These rating were stored electronically in the 
tablet.  The assessment was structured to provide brief educational information about the need 
and asked the patient to rate their confidence in meeting the need on a scale of "0" to "4," 
where "0" meant not confident and "4" meant very confident.  A patient could also rate the 
need as not applicable (NA).  Figure 3 presents an example of two such items.  
 
Not Confident 
 
Very Confident 
NA 
A safe and comfortable place to live 
contributes to your healing and recovery.  
How confident are you that you have a safe 
and comfortable place to live when you leave 
the hospital? 
0 
1 
2 
3 
4 
□ 
You should eat a healthy diet to provide the 
nutrients your body needs to heal.  You may 
need someone to help you get groceries or 
prepare meals for a while.  How confident are 
you that you have someone you can count on 
to help you get groceries and prepare meals 
when you get home?   
0 
1 
2 
3 
4 
□ 
Figure 3: Sample of items from the Rural Transition Needs Assessment and rating scale.   
 
Items rated "2" or less were treated as potential patient needs.  If a patient rated an 
item as "2" or less, the RTC would ask, “Can you tell me a bit more about this?”  She would 
record responses as additional information.  If a patient rated an item as 3 or higher (or NA) but 
that rating seemed incongruent with information learned from the file review or discussion 
with the patient, the RTC would ask, “Can you tell me more about how you will meet that 

  CT.G ROADMAP 11 
 
need?”  This prompt sometimes led to a change in rating.  Again, these explanatory responses 
were recorded as additional information.  LCTCs used this additional information in preparing 
the draft Transitions Plan.    
The patient’s endorsed needs were linked to a database of resources, the Local 
Resource Bank, known to provide services and supports in identified areas of need.  Together, 
the needs and linked services created a patient Transition Agenda (PTA).  Figure 4 shows a 
sample Patient Transition Agenda.   
 
Figure 4: A screen shot of a patient's Transition Agenda listing services available in his 
hometown that he could use to address each identified need in the areas of medication, 
home modifications, and rehabilitation services.   
Electronic Episode of Care.  The RTC posted the patient's Transitions Agenda in the EOC 
tab in Epic® and notified (via EPIC® in-basket email and phone) the LCTC serving the county to 
which the patient was scheduled to return that a patient from the county was being treated at 
SPH and provided an estimated date of discharge.  This early involvement, a component 
insisted on by the key stakeholders from the CAHs, allowed the LCTC to review a patient's 
treatment, risk factors, likely needs, and available resources to meet those needs while the 
patient was still in the hospital.  In addition, the LCTC reviewed the patient’s AVS in EPIC and 
prepared a Discharge Orders Verification Checklist that listed orders and recommendations for 
the patient's recovery at home (e.g., medications, oxygen orders, etc.).   

  CT.G ROADMAP 12 
 
Verifying discharge orders and scheduling a Transitions Conference.  Once discharged 
home (or to a swing bed placement), the LCTC contacted the patient to check on his or her 
status and to schedule a Transition Conference.  The LCTC used the brief Discharge Orders 
Checklist to review the status of each discharge order with a patient.  This was completed 
simply by asking the patient to indicate that an order had been implemented or not.  If the 
checklist revealed any immediate gaps in implementation, the LCTC could take action to help 
the patient address any obstacles in securing the services.  If no immediate gaps were 
identified, the LCTC scheduled a Transitions Conference with the patient.  Then, the LCTC 
notified the patient's primary care provider (PCP) that one of their patients had been treated at 
SPH, had enrolled in the Enhanced Discharge and Rural Transitions study, and provided 
directions for locating the patient's Episode of Care tab in Epic ®. 
Patient Transitions Conference.  The Patient Transition Conference involved the LCTC 
meeting with the patient in their home to review the Transitions Agenda and develop a 
Transitions Plan.  While the preferred setting for the Transitions Conference was the patient’s 
home, this meeting could also take place at the local CAH or even over the phone.  Meeting at 
the patient’s home was preferred because it was seen as helping the LCTC to understand a 
patient better and thought to lead to recognition of needs not previously identified.  It was also 
seen as helping the LCTC judge what types of supports are most likely to fit the patient’s 
context; thus, be more likely to be followed by the patient and caregivers.  Furthermore, the 
Patient Design Team unanimously and strongly encouraged its inclusion in the model.  
Patient Centered Transitions Plan and Supports.  During the Transitions Conference, 
the LCTC reviewed the patient’s Transition Agenda with the patient.  She confirmed the 
identified needs, dropped ones that the patient felt no longer applied, and added any that had 
emerged from the patient's experience in returning home.  Together, they reviewed the 
patient’s personal resources (e.g., family, friends, etc.) and services available locally to address 
the needs, considered their utility and acceptability for the patient, and developed a plan for 
securing needed supports.  The steps were recorded in a Transition Plan form that listed the 
need discussed, the services chosen, and the person responsible for executing each element of 
the plan (e.g., patient to call senior center to arrange transportation).   

  CT.G ROADMAP 13 
 
 In general, the LCTC provided support to the patient for up to 30 days but could extend 
support for up to 90 days.  During that time, the LCTC completed the steps to which she had 
committed and monitored the patient's progress in achieving other objectives.  Progress was 
recorded in the Episode of Care.  After 30 days, the LCTC discussed closing the case with the 
patient.  If the patient agreed, the LCTC discussed a patient's long-range goals and together 
they identified other community supports that the patient might find useful in achieving any 
related objectives.  The LCTC prepared a case summary letter that was sent to the patient, 
posted in the Episode of Care, and sent to the patient's PCP. 
Instructional manual, orientation and training.  Researchers developed a written 
manual using a behavioral instructional format (e.g., Merkel, 1980) to orient and train all staff 
involved in the project.  This involved conducting a detailed task analysis to specify the major 
jobs and tasks required to implement and maintain the experimental procedures.  Each job was 
further analyzed into its component steps.  Researchers prepared behavioral instructions that 
described each step.  These instructions also presented examples of how to perform each step 
and explained the function or outcomes associated with completing each step.   
Staff serving as RTCs and LCTCs read the manual and participated in a day-long 
orientation and training session to review and discuss the procedures.  In addition, SPH 
Information Technology staff trained all research staff in the use of Epic® and the newly created 
Episode of Care component.  Finally, the RTCs and LCTCs participated in weekly teleconferences 
during which they discussed the program's implementation.   
Design 
We used a quasi-experimental time series design with switching replications (Cook & 
Campbell, 1984).  This design involved starting enrolled patients from each of the four counties 
in a baseline condition.  Then, once a stable rate of enrollment had been reached, the 
introduction of the experimental procedures was staggered across patients from each county 
over time.  That is, all patients from one county were enrolled into the intervention while those 
from the other counties remained in baseline.  Later, patients from a second and third county 
were added to the intervention condition while those from the remaining county remained in 
baseline; and so on.  Finally, a return to baseline condition was initiated for patients from all 

  CT.G ROADMAP 14 
 
four counties.  This design protects against most threats to the internal validity of findings and 
many threats to their external validity.  It is particularly helpful in protecting against threats 
posed by seasonal variables.  A final "return to baseline" phase was also included in the study to 
add to protections from threats posed by interactions.   
Baseline and experimental conditions.  Patients in baseline conditions received the 
standard discharge services.  Patients enrolled in the experimental condition received the 
standard discharge services and the Enhanced Discharge Planning and Rural Transition 
Supports.      
Measures.  All patients completed the PAM10 (Hibbard & Mahoney, 2005) and provided 
selected demographic information at the time of enrollment.  Other demographic information 
was collected from each enrolled patient’s medical record.  In addition, we collected the LACE+ 
rating from the medical record and the rating of needs from our Rural Transition Needs 
Assessment.  The LACE+ is a compilation of medical and treatment factors (e.g., chronic 
conditions, previous hospitalizations) derived from a patient's medical record that are used to 
assess risk for re-hospitalization (van Walraven, Wong, & Forster, 2012).    
Researchers prepared an evaluation package that included the three-item Care 
Transition Measure (Coleman, Mahoney, & Parry, 2005), the 12 item Short Form of the Medical 
Outcome Study (Stewart and Ware, 1992), and a Rural Transitions Measure (RTM14; Montana 
Team, 2016).  The RTM14 asked patients to report whether they strongly agree, agree, 
disagree, or strongly disagree with each of 14 statements reflecting services provided after 
discharge to facilitate an effective transition home.  Researchers also asked patients to report 
the number of times that they had seen a PCP, visited an emergency department of any 
hospital, been admitted to SPH, or been admitted to any other hospital since they were 
discharged or since their last report.   
Data collection.  We asked patients to complete the instruments in the evaluation 
package at 3, 7, 14, 21, 30, 60, and 90 days after they were discharged from the RRH.  RTCs 
gave patients the 3 and 7 day evaluation packages in the RRH to complete at home.  The 
research staff mailed the remainder of the evaluation packages to patients three days before 
the end of each measurement period.  Each evaluation package included an instrument and a 

  CT.G ROADMAP 15 
 
self-addressed stamped envelope for returning a completed questionnaire.  In addition, the 
first six instruments included a $10 honoraria and the last packet included a $40 honoraria.   
Finally, we used information in the Epic® patient records to collect demographic data 
and information on emergency department visits, outpatient admissions, and hospitalizations 
at the participating hospitals.  Finally, RTCs and LCTC kept notes detailing the patient situation 
and experiences that were posted in the EOC tab in Epic®.  
Statistical Analysis Plan 
The primary hypotheses address the question of whether the intervention makes a 
difference in the frequency of hospitalizations and emergency department visits.  There are at 
least two ways to view the measurement of these outcomes.  The first is to examine the total 
number of hospital or emergency department visits in each condition.  The second is to 
examine the proportion of patients who have at least one hospital or emergency department 
visits in each condition.  
In addition, there are several intermediary outcomes we anticipate.  These relate to the 
physical and mental health of patients, the rating of the quality of discharge planning services, 
and the rating of the delivery of rural transition services.  We will test the following hypotheses 
using specified procedures:   
1) Hospital re-admissions 
a)  Number of hospital admission 
i) H0i: There is no difference in the cumulative number of hospital admissions for day i 
(null hypothesis); H1i:  The cumulative number of hospital admissions for the 
standard discharge group is greater than that for the enhanced discharge group; for 
days i = 3, 7, 14, 21, 30, 60, 90. 
ii) We will assess the groups for differences using Poisson regression model.  
b) Proportion of patients with at least one hospital admission 
i) H0i: There is no difference in the proportion of patients who report a hospital 
readmission for day i (null hypothesis); H1i:  The proportion of patients who report a 
hospital readmission for the standard discharge group is greater than that for the 
enhanced discharge group; for days i = 3, 7, 14, 21, 30, 60, 90. 

  CT.G ROADMAP 16 
 
ii) We will assess the groups for differences using logistic regression.   
2) Emergency department visits 
a) Number of emergency department visits 
i) H0i: There is no difference in the cumulative number of ED visits for day i (null 
hypothesis); H1i:  The cumulative number of ED visits for the standard discharge 
group is greater than that for the enhanced discharge group; for days i = 3, 7, 14, 21, 
30, 60, 90. 
ii) We will assess the groups for differences using Poisson regression model.  
b) Proportion of emergency department visits 
i) H1i: The proportion of patients who report at least one ED visits for the standard 
discharge group is greater than that for the enhanced discharge group; for days i = 3, 
7, 14, 21, 30, 60, 90. 
ii) We will assess the groups for differences using logistic regression model. 
3) Primary care provider (PCP) visits  
a) Number of PCP visits 
i) H0i: There is no difference in the cumulative number of PCP visits for day i (null 
hypothesis); H1i:  The cumulative number of PCP visits for the standard discharge 
group is greater than that for the enhanced discharge group; for days i = 3, 7, 14, 21, 
30, 60, 90. 
ii) We will assess the groups for differences using Poisson regression model.  
b) Proportion of PCP visits 
i) H0i: There is no difference in the proportion of patients who report at least one  PCP 
visits for day i (null hypothesis); H1i: The proportion of patients who report at least 
one PCP visits for the standard discharge group is greater than that for the enhanced 
discharge group; for days i = 3, 7, 14, 21, 30, 60, 90. 
ii) We will assess the groups for differences using logistic regression model. 
4) Physical health as measured by the Short Form (SF12) functional health score 

  CT.G ROADMAP 17 
 
a) Hoi:  There is no difference in mean SF-12 Physical Health scores between the standard 
and enhanced discharge groups (null hypothesis); H1i: The mean SF-12 Physical Health 
scores differ between the standard and enhanced discharge groups. 
b) We will use a repeated measures ANOVA model (over the 7 time periods) to model the 
SF-12 Physical Health score as a function of treatment group.   
5) Mental Health as measured by the Short Form (SF12) Mental Health Score 
a) Hoi:  There is no difference in mean SF-12 Mental Health scores between the standard 
and enhanced discharge groups (null hypothesis); H1i: The mean SF-12 Mental Health 
scores differ between the standard and enhanced discharge groups. 
b) We will use a repeated measures ANOVA model (over the 7 time periods) to model the 
SF-12 Mental Health score as a function of treatment group. 
6) Care Transition Measure (CTM3) of discharge coordination services 
a) Hoi:  There is no difference in mean CTM3 scores between the standard and enhanced 
discharge groups (null hypothesis); H1i: The mean CTM3 scores differ between the 
standard and enhanced discharge groups. 
b) We will use a repeated measures ANOVA model (one time period at 3 days post 
discharge) to model to assess these hypotheses.   
7) Rural Transition Measure (RTM14) of the delivery of transition services and supports  
a) H0:  There is no difference in the mean RTM14 score between the standard and 
enhanced discharge groups (null hypothesis); H1: Patients in the enhanced discharge 
group will have a higher mean RTM14 rating than patients in the standard discharge 
group. 
b) We will use a repeated measures ANOVA model (over the 6 time periods) to model the 
RTM14 score as a function of treatment group.   
 

  CT.G ROADMAP 18 
 
 
References 
Coleman, EA, Mahoney E, Parry C. Assessing the Quality of Preparation for Post-Hospital Care 
from the Patient's Perspective: The Care Transitions Measure. Medical Care. 2005; 
43(3):246-255. 
Hibbard, J.H., E.R. Mahoney, J. Stockard, M. Tusler.  2005. Development and testing of a short 
form of the Patient Activation Measure. Health Services Research. 2005; 40: 1918 -30. 
Montana Team (2016).  Rural Transitions Needs Assessment: Deciding the help you need.  
Missoula, MT: Rural Institute.   
Stewart, A. & Ware, J.E. (1992).  Measuring Functioning and Well-Being: The Medical Outcomes 
Study Approach.  Durham, NC: Duke University Press Books.   
van Walraven , C., J. Wong, A. J. Forster (2012).  LACE+ index: Extension of a validated index to 
predict early death or urgent readmission after hospital discharge using administrative 
data. Open Medicine, 6(3) e90.