The study tests, in a stepped approach, the impact of implementing discharge readiness assessment by the discharging nurse as standard nursing practice, and the incremental value of informing the nurse assessment with the patient’s perspective, and of requiring that the nurse initiates and documents risk-mitigating actions for patients with low readiness scores.
Aim 1: Determine if discharge readiness assessment by the discharging nurse using the RN-RHDS-short form (RN-RHDS protocol), when implemented as a standard pre-discharge nursing practice, contributes to reduced readmissions and ED visits within 30 days post-discharge.
Aim 2: Determine if nurse assessment informed by patient self-assessment using the PT-RHDS short form contributes to improved post-discharge outcomes (readmission and ED use within 30 days post-discharge) by adding patient’s perspective to the RN-RHDS protocol (RN-RHDS+PT-RHDS protocol).
Aim 3: Determine if adding a structured format for documenting nurse actions triggered by low discharge readiness assessment scores improves patient outcomes (readmission and ED use within 30 days post-discharge
Aim 4: Conduct cost-benefit analysis of implementing discharge readiness assessment as standard practice, by comparing cost-savings from reduced post-discharge utilization against implementation costs.