Please select the eligibility criteria that correspond to the clinical trial below.
Title: READI (Readiness Evaluation And Discharge Interventions): Implementation as a Standard Nursing Practice for Hospital Discharge
Brief Summary: Preparation of patients for discharge is a primary function of hospital-based nursing care and readiness for discharge is an important outcome of hospital care. Inadequacies in discharge preparation have been well-documented and linked to difficulty with self-management after hospital discharge and with increased likelihood of emergency department (ED) use and readmission. Prior studies by the research team have led to recommendations for implementation of discharge readiness assessment as a standard nursing practice for hospital discharge.

The investigators will conduct a multi-site study to determine the impact on post-discharge utilization (readmission and ED visits) and costs of implementing discharge readiness assessment as a standard nursing practice for adult medical-surgical patients discharged to home. The study tests, in a stepped approach, the impact of implementing discharge readiness assessment by the discharging nurse as standard nursing practice (RN-RHDS protocol), the incremental value of informing the nurse assessment with the patient's perspective (RN-RHDS+PT-RHDS protocol), and of requiring that the nurse initiates and documents risk-mitigating actions for patients with low readiness scores (RN-RHDS+PT-RHDS+NIAF protocol).

HYPOTHESIS 1: Patients discharged using the RN-RHDS protocol will have fewer hospital readmissions and ED visits within 30 days post-discharge compared to patients discharged under usual care conditions.

HYPOTHESIS 2: Patients discharged using the RN-RHDS+PT-RHDS protocol will have fewer hospital readmissions and ED visits within 30 days post-discharge compared to patients discharged using the RN-RHDS protocol.

HYPOTHESIS 3: Patients discharged by nurses using the RN-RHDS+PT-RHDS protocol plus a Nurse-Initiated Action Form \[NIAF\] (RN-RHDS+PT-RHDS+NIAF protocol) will have fewer post-discharge readmissions and ED visits than patients discharged using the RN-RHDS+PT-RHDS protocol; the effect will be strongest for patients with low RHDS scores.

Aim 4: Conduct cost-benefit analysis of implementing discharge readiness assessment as standard practice, by comparing cost-savings from reduced post-discharge utilization against implementation costs.


Options:
A: Inclusion Criteria:

* Referred to the renal care services at Aarhus University Hospital or Regional Hospital Central Jutland, Viborg
* Estimated Glomerular Filtration Rate (eGFR) between 10-39 mL/min 1.73m2.
* Aged ≥18 years old
* Ability to provide fully informed written consent for participation in the study

Exclusion Criteria:

* Patients unwilling to participate in PRO-based follow-up
* Patients who, in the opinion of the consenting professional, cannot speak, read or write Danish sufficiently well to complete the PRO questionnaire unaided
* Patients with hearing disabilities
* Patients with an eGFR \> 39mL/min 1.73m2 at their first visit at the hospital
* Patients who have received (or have a scheduled date to receive) a kidney transplant
* A terminal illness that, in the opinion of the consultant assessing eligibility, is likely to lead to the death of the patient within 6 months of starting participation in the study
* Patients receiving chemotherapy, with end stage Chronic Obstructive Lung disease, or with heart failure with Ejection Fraction (EF)\< 15 %.
* A projected risk of progression to end-stage renal failure within 6 months, determined from albumin/creatinine ratio
B: Inclusion Criteria:

* General hospital inpatients with risky drinking (AUDIT-C \>= 4/5 (women/men) and AUDIT \< 20)

Exclusion Criteria:

* Patients already recruited during an earlier hospital stay
* Patients physically and mentally not capable of participating in the study
* Patients with a hospital stay of less than 24 hours
* Patients with insufficient language/ reading skills
* Patients employed at one of the departments participating in the study or conducting the study
* Patients with more severe alcohol problems (AUDIT \>= 20)
C: Inclusion criteria

* Age 18 years and up
* Attends a participating primary health care center in the region
* Diagnosis of mild/moderate depressive disorder (new episode)
* No change in possible antidepressant maintenance therapy during the preceding 1 month
* Provided written informed consent

Exclusion criteria

* Antidepressant medication initiated or changed during the preceding 1 month
* Patient diagnosed with major depressive disorder (BDI-II \>28)
* Patients diagnosed of severe mental psychiatric disorder (i.e. bipolar disorder, antisocial personality disorder, psychosis, substance use disorder or other serious mental disorder)
* Suicidal ideation or intentions
* Inability to speak and understand Swedish language well enough to take part in the activities required in the study.
* Cognitive impairment that makes it impossible to take part in the activities required in the study
* Does not provide written informed consent to participation in the study
D: Inclusion Criteria:

* Medical, surgical, or medical-surgical nursing units of Magnet designated hospitals
* Patients 18 years of age or more, English speaking,able to read and understand consent who are being discharged to home as the discharge destination.
* Nursing personnel (Registered Nurses or Licensed Practical Nurses) who are performing discharge instructions and procedures on the day of hospital discharge.

Exclusion Criteria:

* Patients discharged to home with hospice care.

Answer: D