At a glance
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Rural Options At Discharge Model of Active Planning
In Brief
A clinical study evaluating Enhanced rural discharge and transition for All Causes Hospital Admissions. Completed, enrolled 127 participants.
Detailed 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.
Study Details
Timeline
Interventions
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.