Developing Interventions

Now that you have made a case for improving the discharge transition, pulled together your multidisciplinary team, and understand your current processes regarding discharge, you are ready to think about interventions for improving the discharge process for older adults. Your team may consider a variety of interventions for improving the discharge transition, and the BOOST team offers the following toolkit that addresses many dimensions of the discharge process that your team has identified for improvement.

In thinking about interventions to improve discharge, the BOOST team first identified core principles as central to the interventions. They are:

• Patient centeredness: This concept implies that the intervention focuses on identifying the needs, abilities, and desires of patients and their immediate caregivers (in addition to their outpatient physicians) about safe transition out of the hospital and the abilities of these parties to address those needs. Also embodied in this principle is the idea that all materials and educational efforts are targeted at the language and literacy levels of patients and their caregivers.
  
  
• Empowerment: During the discharge transition preparation process, the hospital care team should address patients’ identified needs and also empower patients and their caregivers to advocate for themselves in the event that further needs arise. Patients and/or caregivers should be provided information about and access to available resources that can assist patients after leaving the hospital. In addition, patients and/or caregivers should be alerted to predictable adversities and their warning signs and symptoms along with a response plan to manage such events. Additionally, patients and caregivers should be given tools for coping with unexpected adverse events and access information to caregivers who can assist with them.
  
  
• Risk appropriateness: Here, risk implies the chance that a patient will suffer an undesirable experience after discharge (e.g. medication error, missed therapy, unplanned rehospitalization, etc.). The literature has identified several risk factors that portend increased risk, and the discharge intervention should be able to help adjust resource utilization around the transition process for patients at higher versus lower risk.
  
  
• Team oriented: The successful transition of a patient out of the hospital typically requires the coordinated efforts of nurses, case managers, social workers, therapists, physicians, and patients and their caregivers. Clear communication throughout the hospitalization is paramount and notably also includes the outpatient medical providers on admission to the hospital, throughout the stay, and during the planning and execution of the transition out of the hospital. Multidisciplinary tools are important to ensure that role delineation and communications occur smoothly. Of note, however, is that it is important that an identifiable role oversees and takes ownership of the process. The role need not be a process/content expert in all elements of the discharge process but rather serve as a coordinator to ensure all parts of the process are completed.
  
  
• Bridging: The transition does not end at the time of hospital discharge. Indeed, medical research clearly indicates patients are at high risk of complications immediately after leaving the hospital and before being seen by outpatient providers. A clear linkage to an accessible care provider after leaving the hospital helps bridge this transition to address issues and questions that arise.

The intervention developed by Project BOOST attempts to incorporate each of these principles.