Racial and Ethnic Disparities in Home Health Referral Among Adult Medicare Patients.

BACKGROUND: Home health care (HHC) services following hospital discharge provide essential continuity of care to mitigate risks of posthospitalization adverse outcomes and readmissions, yet patients from racial and ethnic minority groups are less likely to receive HHC visits. OBJECTIVE: To examine how the association of nurse assessments of patients' readiness for discharge with referral to HHC services at the time of hospital discharge differs by race and ethnic minority group. RESEARCH DESIGN: Secondary data analysis from a multisite study of the implementation of discharge readiness assessments in 31 US hospitals (READI Randomized Clinical Trial: 09/15/2014-03/31/2017), using linear and logistic models adjusted for patient demographic/clinical characteristics and hospital fixed effects. SUBJECTS: All Medicare patients in the study's intervention arm (n=14,684). MEASURES: Patient's race/ethnicity and discharge disposition code for referral to HHC (vs. home) from electronic health records. Patient's Readiness for Hospital Discharge Scale (RHDS) score (0-10 scale) assessed by the discharging nurse on the day of discharge. RESULTS: Adjusted RHDS scores were similar for non-Hispanic White (8.21; 95% CI: 8.18-8.24), non-Hispanic Black (8.20; 95% CI: 8.12-8.28), Hispanic (7.92; 95% CI: 7.81-8.02), and other race/ethnicity patients (8.09; 95% CI: 8.01-8.17). Non-Hispanic Black patients with low RHDS scores (6 or less) were less likely than non-Hispanic White patients to be discharged with an HHC referral (Black: 26.8%, 95% CI: 23.3-30.3; White: 32.6%, 95% CI: 31.1-34.1). CONCLUSIONS: Despite similar RHDS scores, Black patients were less likely to be discharged with HHC. A better understanding of root causes is needed to address systemic structural injustice in health care settings.

Effect of Implementing Discharge Readiness Assessment in Adult Medical-Surgical Units on 30-Day Return to Hospital: The READI Randomized Clinical Trial.

Importance: The downward trend in readmissions has recently slowed. New enhancements to hospital readmission reduction efforts are needed. Structured assessment of patient readiness for discharge has been recommended as an addition to discharge preparation standards of care to assist with tailoring of risk-mitigating actions. Objective: To determine the effect of unit-based implementation of readiness evaluation and discharge intervention protocols on readmissions and emergency department or observation visits. Design, Setting, and Participants: The Readiness Evaluation and Discharge Interventions (READI) cluster randomized clinical trial conducted in medical-surgical units of 33 Magnet hospitals between September 15, 2014, and March 31, 2017, included all adult (aged ≥18 years) patients discharged to home. Baseline and risk-adjusted intent-to-treat analyses used difference-in-differences multilevel logistic regression models with controls for patient characteristics. Interventions: Of 2 adult medical-surgical nursing units from each hospital, 1 was randomized to the intervention and 1 to usual care conditions. Using the 8-item Readiness for Hospital Discharge Scale, the 33 intervention units implemented a sequence of protocols with increasing numbers of components: READI1, in which nurses assessed patients to inform discharge preparation; READI2, which added patient self-assessment; and READI3, which added an instruction to act on a specified Readiness for Hospital Discharge Scale cutoff score indicative of low readiness. Main Outcomes and Measures: Thirty-day return to hospital (readmission or emergency department and observation visits). Intervention units above median baseline readmission rate (>11.3%) were categorized as high-readmission units. Among the 33 intervention units, 17 were low-readmission units and 16 were high-readmission units. Results: The sample included 144 868 patient discharges (mean [SD] age, 59.6 [17.5] years; 51% female; 74 605 in the intervention group and 70 263 in the control group); 17 667 (12.2%) were readmitted and 12 732 (8.8%) had an emergency department visit or observation stay. None of the READI protocols reduced the primary outcome of return to hospital in intent-to-treat analysis of the full sample. In exploratory subgroup analysis, when patient self-assessments were combined with readiness assessment by nurses (READI2), readmissions were reduced by 1.79 percentage points (95% CI, -3.20 to -0.40 percentage points; P = .009) on high-readmission units. With nurse assessment alone and on low-readmission units, results were mixed. Conclusions and Relevance: Implemented in a broad range of hospitals and patients, the READI interventions were not effective in reducing return to hospital. However, adding a structured discharge readiness assessment that incorporates the patient's own perspective to usual discharge care practices holds promise for mitigating high rates of return to the hospital following discharge. Trial Registration: ClinicalTrials.gov Identifier: NCT01873118.

Aligning Evidence-Based Practice With Translational Research: Opportunities for Clinical Practice Research.

Magnet® and other organizations investing resources in evidence-based practice (EBP) are ideal laboratories for translational nursing research. Translational research, the study of implementation of evidence into practice, provides a unique opportunity to leverage local EBP work for maximum impact. Aligning EBP projects with rigorous translational research can efficiently meet both EBP and research requirements for Magnet designation or redesignation, inform clinical practice, and place organizations at the leading edge of practice-based knowledge development for the nursing discipline.

Validation of the Registered Nurse Assessment of Readiness for Hospital Discharge Scale.

BACKGROUND: Statistical models for predicting readmissions have been published for high-risk patient populations but typically focus on patient characteristics; nurse judgment is rarely considered in a formalized way to supplement prediction models. OBJECTIVES: The purpose of this study was to determine psychometric properties of long and short forms of the Registered Nurse Readiness for Hospital Discharge Scale (RN-RHDS), including reliability, factor structure, and predictive validity. METHODS: Data were aggregated from two studies conducted at four hospitals in the Midwestern United States. The RN-RHDS was completed within 4 hours before hospital discharge by the discharging nurse. Data on readmissions and emergency department visits within 30 days were extracted from electronic medical records. RESULTS: The RN-RHDS, both long and short forms, demonstrate acceptable reliability (Cronbach's alphas of .90 and .73, respectively). Confirmatory factor analysis demonstrated less than adequate fit with the same four-factor structure observed in the patient version. Exploratory factor analysis identified three factors, explaining 60.2% of the variance. When nurses rate patients as less ready to go home (<7 out of 10), patients are 6.4-9.3 times more likely to return to the hospital within 30 days, in adjusted models. DISCUSSION: The RN-RHDS, long and short forms, can be used to identify medical-surgical patients at risk for potential unplanned return to hospital within 30 days, allowing nurses to use their clinical judgment to implement interventions prior to discharge. Use of the RN-RHDS could enhance current readmission risk prediction models.

Economic evaluation of the 80% baccalaureate nurse workforce recommendation: a patient-level analysis.

BACKGROUND: Higher proportions of BSN-educated nurses were associated with improved outcomes in hospital-level studies. A recent Institute of Medicine report calls for increasing the proportion of BSN-educated nurses to 80% by 2020. Patient-level evidence of cost and quality implications of the 80% BSN threshold is needed for a business case to support these efforts. OBJECTIVES: To conduct the economic analysis of meeting the 80% BSN threshold on patient outcomes and costs, using linked patient-nurse data. RESEARCH DESIGN: Retrospective observational patient-level analysis of electronic data. Linear and logistic regression modeling with patient controls and diagnosis and unit fixed effects. SUBJECTS: A total of 8526 adult medical-surgical patients matched with 1477 direct care nurses from an Eastern US academic medical center, during June 1, 2011-December 31, 2011. MEASURES: Outcomes include hospital mortality, all-cause same-facility 30-day readmission, length-of-stay, and total hospitalization cost. BSN proportion is a continuous measure for the proportion of nurse assessment inputs into the patient's electronic medical record made by BSN-educated nurses; a dichotomous indicator for BSN proportion is 0.8-1.0. RESULTS: Continuous BSN proportion was associated with lower mortality (OR=0.891, P<0.01). Compared with patients with <80% BSN care, patients receiving ≥ 80% of care from BSN nurses had lower odds of readmission (OR=0.813, P=0.04) and 1.9% shorter length-of-stay (P=0.03). Economic simulations support a strong business case for increasing the proportion of BSN-educated nurses to 80%. CONCLUSIONS: A combined approach of increasing the hospital-level BSN proportion to 80% and assuring a high BSN dose through individual patient-level staffing assignments is needed to achieve projected quality and costs benefits.

Measuring nurses' impact on health care quality: progress, challenges, and future directions.

BACKGROUND: Quality measurement is central in efforts to improve health care delivery and financing. The Interdisciplinary Nursing Quality Research Initiative supported interdisciplinary research teams to address gaps in measuring the contributions of nursing to quality care. OBJECTIVE: To summarize the research of 4 interdisciplinary teams funded by The Interdisciplinary Nursing Quality Research Initiative and reflect on challenges and future directions to improving quality measurement. METHODS: Each team summarized their work including the targeted gap in measurement, the methods used, key results, and next steps. The authors discussed key challenges and recommended future directions. RESULTS: These exemplar projects addressed cross-cutting issues related to quality; developed measures of patient experience; tested new ways to model the important relationships between structure, process, and outcome; measured care across the continuum; focused on positive aspects of care; examined the relationship of nursing care with outcomes; and measured both nursing and interdisciplinary care. DISCUSSION: Challenges include: measuring care delivery from multiple perspectives; determining the dose of care delivered; and measuring the entire care process. Meaningful measures that are simple, feasible, affordable, and integrated into the care delivery system and electronic health record are needed. Advances in health information systems create opportunities to advance quality measurement in innovative ways. CONCLUSIONS: These findings and products add to the robust set of measures needed to measure nurses' contributions to the care of hospitalized patients. The implementation of these projects has been rich with lessons about the ongoing challenges related to quality measurement.

Outcomes and cost analysis of the impact of unit-level nurse staffing on post-discharg utilization.

Under a proposal from the Centers for Medicare and Medicaid Services, hospitals would no longer be reimbursed for 30-day re-admissions or emergency department (ED) visits. Increasing RN staffing to reduce post-discharge utilization is one possible solution, but one that is not financially attractive to hospitals. This study demonstrates the impact of fluctuating staffing levels on ED visits within 30 days of discharge. RN overtime and RN vacancies also affected subsequent ED visits. It is important for nurse managers, directors, and administrators to recognize the impact of RN staffing on patient outcomes. Reimbursement models will need to be realigned to benefit both hospitals and payers.

Quality and cost analysis of nurse staffing, discharge preparation, and postdischarge utilization.

OBJECTIVES: To determine the impact of unit-level nurse staffing on quality of discharge teaching, patient perception of discharge readiness, and postdischarge readmission and emergency department (ED) visits, and cost-benefit of adjustments to unit nurse staffing. DATA SOURCES: Patient questionnaires, electronic medical records, and administrative data for 1,892 medical-surgical patients from 16 nursing units within four acute care hospitals between January and July 2008. DESIGN: Nested panel data with hospital and unit-level fixed effects and patient and unit-level control variables. DATA COLLECTION/EXTRACTION: Registered nurse (RN) staffing was recorded monthly in hours-per-patient-day. Patient questionnaires were completed before discharge. Thirty-day readmission and ED use with reimbursement data were obtained by cross-hospital electronic searches. PRINCIPAL FINDINGS: Higher RN nonovertime staffing decreased odds of readmission (OR=0.56); higher RN overtime staffing increased odds of ED visit (OR=1.70). RN nonovertime staffing reduced ED visits indirectly, via a sequential path through discharge teaching quality and discharge readiness. Cost analysis projected total savings from 1 SD increase in RN nonovertime staffing and decrease in RN overtime of U.S.$11.64 million and U.S.$544,000 annually for the 16 study units. CONCLUSIONS: Postdischarge utilization costs could potentially be reduced by investment in nursing care hours to better prepare patients before hospital discharge.

Nurse and patient perceptions of discharge readiness in relation to postdischarge utilization.

BACKGROUND: Prevention of hospital readmission and emergency department (ED) utilization will be a crucial strategy in reducing health care costs. There has been limited research on nurse assessment and patient perceptions of discharge readiness in relation to postdischarge outcomes. OBJECTIVES: To investigate the association of nurse and patient assessments of discharge readiness with postdischarge readmissions and ED visits. RESEARCH DESIGN: Hierarchical regression analysis of readmission or ED utilization using independent nurse and patient assessments of discharge readiness and patient characteristics as explanatory variables, with hospital and unit fixed effects. SUBJECTS: A total of 162 adult medical-surgical patients and their discharging nurses from 13 medical-surgical units of 4 Midwestern hospitals. MEASURES: Readiness for Hospital Discharge Scale completed independently by patients and their discharging nurses within 4 hours before hospital discharge; Postdischarge utilization (unplanned readmission or ED visit within 30 days postdischarge). RESULTS: Correlations between nurse assessment and patient perceptions of discharge readiness were low (r = 0.15-0.32). Nurses rated patient readiness higher than patients themselves. Controlling for patient characteristics, nurse readiness for hospital discharge scale score (odds ratio = 0.57, P = 0.05) but not patient readiness for hospital discharge scale score was associated with postdischarge utilization. CONCLUSIONS: Nurse assessment was more strongly associated with postdischarge utilization than patient self-assessment. Formalizing nurse assessment of discharge readiness could facilitate identification of patients at risk for readmission or ED utilization before discharge when anticipatory interventions could prevent avoidable postdischarge utilization.

Predictors and outcomes of postpartum mothers' perceptions of readiness for discharge after birth.

OBJECTIVE: To identify predictors and outcomes of postpartum mothers' perceptions of their readiness for hospital discharge. DESIGN: A correlational design with path analyses was used to explore predictive relationships among transition theory-related variables. SETTING: Midwestern tertiary perinatal center. PARTICIPANTS: One hundred and forty-one mixed-parity postpartum mothers who had experienced vaginal birth or Cesarean delivery of normal healthy infants. METHODS: Before hospital discharge, patients completed questionnaires about sociodemographic characteristics, hospitalization factors, quality of discharge teaching, and readiness for discharge. Three weeks postdischarge, mothers were contacted by telephone to collect coping difficulty and health care utilization data. MAIN OUTCOME MEASURES: Readiness for Hospital Discharge Scale, Post-Discharge Coping Difficulty Scale, Utilization of postdischarge services. RESULTS: Quality of discharge teaching, specifically the relative difference in the amount of informational content needed and received and the skills of nurses in delivering discharge teaching, explained 38% of the variance in postpartum mothers' perceptions of discharge readiness. Readiness for discharge scores explained 22% of the variance in postdischarge coping difficulty scores. Nurses' skills in delivery of discharge teaching, coping difficulty, patient characteristics, and birth hospitalization factors were predictive of utilization of family support and postdischarge health care services. CONCLUSION: A trajectory of influence was evident in the sequential relationships of quality of discharge teaching, readiness for discharge, postdischarge coping, and utilization of family support and health care services. Transitions theory provided a useful framework for conceptualizing and investigating the transition home after childbirth.

Patients' perceptions of hospital discharge informational content.

Ensuring that patients' informational needs have been met prior to hospital discharge sets the stage for successful self-management of recovery at home. This secondary analysis study aims to identify differences in the amount of discharge teaching content needed and received by adult medical-surgical patients on the basis of their sociodemographic characteristics and hospitalization-related factors. The Quality of Discharge Teaching Scale (QDTS) is used to measure patients' perceptions of the amount of discharge-related informational content they needed and received. Eighty-nine percent of patients receive more informational content than they perceived they needed. Nonwhite patients report more content needed than White patients. Patients with prior hospitalizations and cardiac patients report greater amounts of content received. The QDTS content subscales provide a mechanism for assessing patient perceptions of discharge informational needs and discharge content received that can be used for clinical practice and quality monitoring.

Validity and reliability of the Perceived Readiness for Discharge After Birth Scale.

OBJECTIVE: To assess the psychometric properties of a scale measuring mothers' perceptions of readiness for discharge after birth. DESIGN: Psychometric analyses including construct validity using factor analysis and known groups comparisons, predictive validity, and reliability. Data were collected at discharge and 6 weeks postdischarge. SETTING: Tertiary-level perinatal center in the Midwestern United States. PARTICIPANTS: 1,462 postpartum mothers. INTERVENTION: None. MAIN OUTCOME MEASURES: Perceived Readiness for Discharge After Birth Scale scores; subscale scores for personal status and knowledge factors. RESULTS: Exploratory and confirmatory factor analyses indicated that the scale contained two factors. Perceived Readiness for Discharge After Birth Scale scores were lower for mothers who were breastfeeding, married, primiparous, and had a short hospital stay (less than 30 hours) than for their comparison groups. The Perceived Readiness for Discharge After Birth Scale personal status factor was predictive of self-reported physical and psychosocial problems and unscheduled utilization of health services in the first 6 weeks postpartum. The knowledge factor was predictive of postdischarge telephone calls to the pediatric provider. Reliability estimates ranged from 0.83 to 0.89 for the total scale and subscales. CONCLUSIONS: The Perceived Readiness for Discharge After Birth Scale performed well in psychometric testing. Assessing mothers' perceptions of readiness for discharge is important for measuring outcomes of hospitalization and for identifying mothers at risk for postdischarge problems.

Psychometric properties of the Readiness for Hospital Discharge Scale.

The purpose of the study was to assess the psychometrics properties of the Readiness for Hospital Discharge Scale (RHDS), a 23-item instrument that measures patients' perception of readiness for discharge. Data were obtained from 356 respondents from two urban tertiary medical centers (adult and children's) in the midwestern United States who were participants in a larger study of predictors and outcomes of readiness for hospital discharge. Confirmatory factor analysis, contrasted group comparisons, and predictive validity testing supported the 4-factor structure and construct validity of the instrument. Following deletion of two poorly performing items, Cronbach's alpha for the revised 21-item scale was 0.90. The RHDS can be a useful tool for measurement of readiness for discharge for clinical and research purposes.

Length of stay after vaginal birth: sociodemographic and readiness-for-discharge factors.

BACKGROUND: The impact of reductions in postpartum length of stay have been widely reported, but factors influencing length of hospital stay after vaginal birth have received less attention. The study purpose was to compare the sociodemographic characteristics and readiness for discharge of new mothers and their newborns at 3 discharge time intervals, and to determine which variables were associated with postpartum length of stay. METHODS: The study sample comprised 1,192 mothers who were discharged within 2 postpartum days after uncomplicated vaginal birth at a tertiary perinatal center in the midwestern United States. The sample was divided into 3 postpartum length-of-stay groups: group 1 (18-30 hr), group 2 (31-42 hr), and group 3 (43-54 hr). Sociodemographic and readiness-for-discharge data were collected by self-report and from a computerized hospital information system. Measures of readiness for discharge included perceived readiness (single item and Readiness for Discharge After Birth Scale), documented maternal and neonatal clinical problems, and feeding method. RESULTS: Compared with other groups, the longest length-of-stay group was older; of higher socioeconomic status and education; and with more primiparous, breastfeeding, white, married mothers who were living with the baby's father, had adequate home help, and had a private payor source. This group also reported greater readiness for discharge, but their newborns had more documented clinical problems during the postbirth hospitalization. In logistic regression modeling, earlier discharge was associated with young age, multiparity, public payor source, low socioeconomic status, lack of readiness for discharge, bottle-feeding, and absence of a neonatal clinical problem. CONCLUSIONS: Sociodemographic characteristics and readiness for discharge (clinical and perceived) were associated with length of postpartum hospital stay. Length of stay is an outcome of a complex interface between patient, provider, and payor influences on discharge timing that requires additional study. Including perceived readiness for discharge in clinical discharge criteria will add an important dimension to assessment of readiness for discharge after birth.