Rural Options At Discharge Model of Active Planning
Condition: All Causes Hospital Admissions
Study type: Interventional

Summary: 
      Residents of rural and frontier counties experience significant disparities in health care
      access and outcomes when compared to their urban counterparts. The organization of health
      care delivery contributes significantly to these disparities. For rural residents with
      multiple chronic conditions, transitioning along the continuum of care, between systems of
      treatment and support, and between dispersed locations present significant challenges. One
      critical challenge involves hospitalization for treatment because it requires travel to
      locations at a significant distance from home and disrupts personal and family routines. The
      transition back home is also problematic because discharge planning does not adequately
      account for limited access to care in rural areas. Indeed, discharge planning has been
      recently described as a "black hole;" fragmented and uncoordinated, and contributing to poor
      outcomes and patient dissatisfaction. The specific aim of this research is 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 options discharge
      model (ROADMAP) that improves patient outcomes and reduces re-hospitalizations.
    

Detailed description: 
      Residents of rural counties experience significant disparities in health care access and
      outcomes when compared to their urban counterparts. These disparities are structural; based
      in our market-based medical care delivery system. For rural residents with multiple chronic
      conditions, transitioning along the continuum of care, between systems of treatment and
      support, and between dispersed locations both expose and produce disparities. The transition
      home from hospitalization for treatment exposes the current urban bias. Indeed, discharge
      planning is fragmented and uncoordinated, and contributes to poor the disparities. The
      specific aims of this research is to ascertain rural patients' actual experience of
      discharge; then to involve patients and rural providers in using those data to design a
      contextually appropriate rural options at discharge model of active planning (ROADMAP) that
      improves patient outcomes and reduces disparities. Objectives include:

        1. Ascertain actual patient experience in the rural discharge process.

        2. Design the ROADMAP model to fit the emerging health services context.

        3. Test the ROADMAP's efficacy in enhancing patient defined outcomes.

        4. Design the components for rapid diffusion.

      Researchers will work in four counties of the Missoula Hospital Referral Region with a total
      population of 53,116 living on 12,342 square miles (4.3 persons per square mile). Researchers
      will recruit patients seeking treatment from St. Patrick Hospital. Patients and patient
      advocates will serve on an Innovations Design Team (IDT) to create the ROADMAP. Researchers
      will first interview patients (n = 40) who have been discharged to one of the rural counties.
      Researchers will compare their experiences to guidelines. Next, they will conduct a Design
      Survey (n=600) to verify goals important to patients. The IDT will use these findings to
      develop design requirements for ROADMAP. Finally, we will use a quasi-experimental research
      design to compare the patient designed rural ROADMAP to standard practice. The primary
      outcome measures are measures that reflect the patient's values for health-related quality of
      life and functional status, as well as hospital re-admissions. An independent statistician
      will use Hierarchical Linear Modeling to examine the complex relationships. This approach
      accounts for patients nested in four counties and the correlated errors inherent in within
      subject analysis. Health care reform sets the occasion for rapid diffusion of ROADMAP. This
      can provide an incremental reduction in rural disparities. Incorporating patient and provider
      input increases the likelihood it will fit within the emerging reimbursement model.
      Researchers expect that ROADMAP will reduce re-hospitalizations by as much as 30%, and
      improve patient recovery and return to participation in daily life.
    

Intervention name(s): Enhanced rural discharge and transition
Intervention type(s): Behavioral
Intervention description(s): While in the treating hospital, patients from small towns and rural communities are engaged in package of procedures designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of enhanced recovery supports to the patient.
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Intervention model description: Patients were recruited from those admitted from one of four rural counties. In the initial phase, all patients enrolled from any county were assigned to a baseline condition. After enrollment stabilized, patients from one county were enrolled in the intervention while patients from the other three counties remained in baseline. Subsequently the intervention was introduced to the other counties sequentially while others remained in baseline. A return to baseline conditions followed a period after the intervention had been introduced in all counties.
Masking: Single (Participant)
Primary purpose: Supportive Care