Models of Discharge Care in Magnet® Hospitals.

OBJECTIVE: The aim of this article is to describe how the discharge preparation process is operationalized in Magnet® hospitals. BACKGROUND: Nationally, there are intensive efforts toward improving discharge transitions and reducing readmissions. Discharge preparation is a core hospital function, yet there are few reports of operational models. METHODS: This was a descriptive, Web-based survey of 32 Magnet hospitals (64 units) participating in the Readiness Evaluation and Discharge Interventions study. RESULTS: Most hospitals have adopted 1 or more national readmission reduction initiatives. Most unit models include several discharge preparation roles; RN case managers, and discharging RNs lead the process. Nearly one-half of units actively screen for readmission risk. More than three-fourths report daily discharge rounds, but less than one-third include the patient and family. More than two-thirds report a follow-up phone call, mostly to assess patient satisfaction. CONCLUSIONS: Magnet hospitals operationalize discharge preparation differently. Recommended practices from national discharge initiatives are inconsistently used. RNs play a central role in discharge planning, coordination, and teaching.