Please select the arm or intervention descriptions that belong 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: Arm Label: PRO-based follow-up; Type: EXPERIMENTAL; Interventions: Behavioral: PRO-based follow-up | Arm Label: PRO-based telephone consultations; Type: EXPERIMENTAL; Interventions: Behavioral: PRO-based telephone consultation | Arm Label: Usual outpatient follow-up visits; Type: NO_INTERVENTION; Interventions: N/A | Intervention Type: BEHAVIORAL; Name: PRO-based follow-up; Assigned to Arm(s): PRO-based follow-up | Intervention Type: BEHAVIORAL; Name: PRO-based telephone consultation; Assigned to Arm(s): PRO-based telephone consultations
B: Arm Label: Personal counseling; Type: EXPERIMENTAL; Interventions: Behavioral: Personal Counseling | Arm Label: Computer generated feedback letters; Type: EXPERIMENTAL; Interventions: Behavioral: Computer-generated feedback letters | Arm Label: Control group; Type: NO_INTERVENTION; Interventions: N/A | Intervention Type: BEHAVIORAL; Name: Personal Counseling; Assigned to Arm(s): Personal counseling | Intervention Type: BEHAVIORAL; Name: Computer-generated feedback letters; Assigned to Arm(s): Computer generated feedback letters
C: Arm Label: Structured patient visits; Type: OTHER; Interventions: Behavioral: Structured patient-centered follow up of depression | Arm Label: Treatment as usual; Type: OTHER; Interventions: Behavioral: Structured patient-centered follow up of depression | Intervention Type: BEHAVIORAL; Name: Structured patient-centered follow up of depression; Assigned to Arm(s): Structured patient visits, Treatment as usual
D: Arm Label: Usual Care Control hospital unit; Type: NO_INTERVENTION; Interventions: N/A | Arm Label: implementation unit; Type: EXPERIMENTAL; Interventions: Other: RN-RHDS protocol, Other: RN-RHDS+PT-RHDS protocol, Other: RN-RHDS + PT-RHDS + NIAF | Intervention Type: OTHER; Name: RN-RHDS protocol; Assigned to Arm(s): implementation unit | Intervention Type: OTHER; Name: RN-RHDS+PT-RHDS protocol; Assigned to Arm(s): implementation unit | Intervention Type: OTHER; Name: RN-RHDS + PT-RHDS + NIAF; Assigned to Arm(s): implementation unit

Answer: D