CE 1.5 ANCC Contact Hours Vol. 22 , No. 5 , 214 - 227

214 Professional Case Management Vol. 22/No. 5

CE 1.5 ANCCContact Hours

The University of Utah College of Nursing, Annette Poulson Cumming Building Rm 5635, 10 South 2000 East, Salt Lake City, UT 84112-5880, The University of Iowa College of Nurs-ing, 50 Newton Road, Iowa City, IA 52242, Mercy Medical Center, Clinton, Iowa, 1410 N. 4th St., Clinton, IA 52732.

Address correspondence to Andrea Wallace, PhD, RN, The University of Utah College of Nursing, Annette Poulson

A B S T R A C T Purpose of Study: Despite over three decades of research linking social support and optimal health outcomes, social support is not systematically assessed or addressed during clinical care. This study sought input from health care providers to inform the design of an intervention intended to facilitate assessment of social support in a way that could aid in anticipatory planning during the process of hospital discharge. Primary Practice Setting(s): Using a purposive sampling strategy, data were collected from providers in two acute care settings serving rural patients, one academic and one community based. Opinions about what an assessment of social support would seek to accomplish, what is currently done and by whom, and the preferred format for delivery were elicited during a series of individual and group interviews. During phase two, feasibility was assessed with three inpatient nurses over 3 clinical days. Field notes were analyzed throughout the project using rapid data analysis techniques. Results: Health care providers endorsed the creation of an assessment and stated that target users would include all members of the discharge team (e.g., clinical nurses, case managers, discharge coordinators, hospitalists, and specialty care). They identifi ed the need for a patient–family resource (vs. a traditional provider-facing assessment). Participants stated that, although both the information collected and the interview process would meet a need to increase patient engagement in inpatient settings, competing clinical demands would require a tool that was easily completed by patients and family and seen as directly informing clinical activities. To this end, although focusing on the eventual development of an electronic tool seemed valuable, a hard-copy resource was considered more feasible for patient use at the present time. The preliminary test of the resulting hard-copy “Going Home Toolkit” demonstrated potential feasibility and usefulness during clinical practice. Implications for Case Management Practice: There is need for not only assessing patients’ supportive networks during discharge planning, but to do so in a way that would facilitate directed communication between, and engagement with, team members, patients, and families. Especially in light of new legislation focusing on involvement of caregivers, a tool such as the “Going Home Toolkit” may facilitate important conversations about, and planning around, patients’ supportive resources at home.

Key words: caregivers , hospital discharge , readmission , social support

Provider Opinions and Experiences Regarding Development of a Social Support Assessment to Inform Hospital Discharge The Going Home Toolkit

Andrea Wallace , PhD, RN , Todd Papke , PhD , Erica Davisson , MSN, RN , Kara Spooner , MSN , and

Laura Gassman , MHA, BSN, RNC-EFM

DOI: 10.1097/NCM.0000000000000234

Professional Case Management Vol. 22 , No. 5 , 214 - 227

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Cumming Building Rm 5635, 10 South 2000 East, Salt Lake City, UT 84112 ( [email protected] ).

Funding for this work was provided by the University of Iowa Offi ce of Engagement and Outreach.

The authors report no confl icts of interest.

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Vol. 22/No. 5 Professional Case Management 215

The hospital discharge process is complex and fraught with problems as a result of increas-ing complexity of medical conditions, declining

lengths of stay, and increasing reliance on hospitalists that have a limited understanding of patients’ out-patient care and needs ( Bench, Cornish, & Xyrichis, 2016 ; Billings, Dixon, Mijanovich, & Wenneberg, 2006 ; Harrison, Greysen, Jacolbia, Nguyen, & Auer-bach, 2016 ; Hauer, Wachter, McCulloch, Woo, & Auerbach, 2004 ; Moore, Wisnivesky, Williams, & McGinn, 2003 ; Wachter, 2004 ). These factors col-lectively increase the need for patients to engage in complex tasks, or to “self-manage” their condition at home. However, patients do not manage their con-dition in isolation, but in the context of their daily lives with the people who comprise their supportive networks—family, friends, colleagues, and neighbors who assist in meeting patients’ needs. Most of the research about care giving has focused on those caring for frail and dependent older adults and those with cancer, but data suggest that even largely independent adults rely on a social support network to meet their health-related needs at home ( Wallace, Driessnack, Bohr, & Tripp-Reimer, 2015 ). These fi ndings echo others who have documented that the majority of patients with common chronic illnesses rely on mul-tiple family members to assist with their conditions ( Piette, Rosland, Silveira, Kabeto, & Langa, 2010 ; Rosland, Heisler, Choi, Silveira, & Piette, 2010 ).

Hospital discharge is a time during which patients and their families report feeling abandoned by health care professionals, primarily because they are not prepared for the challenges ahead of them and they are not referred to support services in their home communities ( Harrison et al., 2016 ; Howard-Ander-son, Busuttil, Lonowski, Vangala, & Afsar-Manesh, 2016 ; Levine, 1998 ). One reason for this may be a lack of agreement among health care providers, patients, and caregivers about patients’ needs after discharge: data show that nurses lack awareness of patients’ resources at home, which limits their ability to provide adequate postdischarge planning ( Rose, Bowman, & Kresevic, 2000 ), and there is frequently disagreement among patients and nurses regarding discharge readiness, a variable associated with future need to access emergency services ( Weiss, Yakusheva, & Bobay, 2010 ). These fi ndings suggest that facili-tating communication between patients and health care providers about personal resources at home may improve patients’ experiences and health outcomes after hospitalization.

There is a growing body of work regarding the effectiveness of programs focusing on “care tran-sitions” on improving postdischarge outcomes. Although these programs vary ( Coleman, Parry, Chalmers, & Min, 2006 ; Jack et al., 2009 ; Lovelace

et al., 2016 ; Naylor et al., 1994 ), effective pro-grams appear to be those emphasizing “the patient or caregiver in maintaining safe transitions” ( Han-sen, Young, Hinami, Leung, & Williams, 2011 , p. 526). As such, consensus standards propose that care transitions be guided by 10 principles, three of which directly mention communication with patients and caregivers ( Hunter, Nelson, & Birmingham, 2013 ; Snow et al., 2009 ). The Centers for Medicare & Medicaid Services has adopted these principles by stating that patients, family, guardians, and/or caregivers need to be educated regarding self-man-agement, independent living, and activities of daily living to be reimbursed for “care management” services ( American Academy of Family Physicians, 2013 ; Centers for Medicare & Medicaid Services, 2015, n.d. ). However, while engaging patients and their support networks is emphasized by these clini-cian groups and payors, they have failed to recom-mend a structure for eliciting patients’ perceptions of their needs and resources at home, and little work focused specifi cally on building partnerships between patients, families, and health care providers who help plan hospital discharge ( Popejoy, Moylan, & Galambos, 2009 ). With newly emerging legislation related to caregiver involvement (e.g., the Caregiver Advise, Record, Enable Act) ( American Association of Retired Persons, 2015 ), it is increasingly important to develop strategies for effectively identifying and engaging those in patients’ lives who are supportive of self-management efforts at home.

ADAPTING A RESEARCH INSTRUMENT FOR USE DURING CLINICAL CARE

A potential reason for why social support has not been more fully considered during clinical care is that, although successfully applied in research settings, instruments purporting to describe clients’ social net-works and their effects on health are not designed to be used in busy clinical settings: They lack visual appeal, are generally structured, lengthy, and do not commonly address relational characteristics that may infl uence patients’ ability to engage in self-management at home. As such, in a recent pilot study exploring the social support network of patients with diabetes, we successfully adapted the Colored Ecogenetic Relation-ship Map (CEGRM) with the purpose of identifying a range of individuals providing instrumental (educa-tional and tangible) support to patients with diabetes ( Wallace et al., 2015 ). The results of the pilot study were encouraging in that the adapted D -CEGRM (1) successfully elicited unique information about a network of persons (family, neighbors, coworkers, friends, church groups, and veteran support groups) who provide instrumental support (for diet, insurance,



medication, and transportation) to complex patients with diabetes; (2) facilitated a positive exchange between patients and clinician-researchers; and (3) demonstrated feasibility, with research assistants, who were trained in its use in less than 30 min and com-pleted the patient interview in 10–15 min.

The CEGRM—which is nested within a social system perspective with an emphasis on social exchange theory and network analysis—is a simple process using a semistructured script to guide par-ticipants in visually identifying, with differently colored symbols, individuals who provide various types of social support (informational, tangible, emotional, and spiritual/religious). When used to identify the social networks related to the commu-nication of genetic risk among adults, where studies have demonstrated that it is an informative tool to better understand the social and emotional landscape accompanying health diagnoses, where socially sup-portive exchanges within and outside the family can be counted and individuals identifi ed ( Koehly et al., 2009 ; Peters, Hoskins, Prindiville, Kenen, & Greene, 2006 ; Peters et al., 2004 , 2012). However, on the basis of an adaptation of the CEGRM for children ( Driessnack, 2009 ), our adapted D -CEGRM involved a simple process of creating a crude paper-and-pencil/pen genogram on a blank 8.5˝ × 11˝ piece of paper, and taking patients through the process of identify-ing family members and others who were helpful and problematic with patients’ efforts to manage their diet, insurance, medication, and transportation ( Wallace, Driessnack, Bohr, & Tripp-Reimer, 2015 ).

Based on collective experience with the CEGRM instrument and its adaptations, and the need to create means for effi ciently and effectively assessing social support during acute hospitalizations, the purpose of this study was to understand whether and how the CEGRM might serve as a template to develop means of assessing patients’ social resources supportive of their self-management after hospital discharge. This article addresses the fi rst phases of intervention devel-opment, during which the research team engaged stakeholders (clinicians and administrators already assembled as part of quality improvement efforts in an academic medical center and in a rural, Magnet-Designated hospital in a community-based setting) in a series of meetings to gain a better understanding of their experiences, as they try to support rural patients returning home after hospitalization. There was con-tinual feedback by both patients and experts through-out the process. The research team also sought feed-back about what kind of instrument (i.e., paper and pencil, web-based application, design and layout, and where it would be used) could be incorporated into their clinical practice. The central questions guiding this work were (1) what are the essential elements

needed to support patient involvement in the tran-sitional care plan and communication of key social support information to health care providers; and 2) what are the workfl ow requirements needed to sup-port the implementation of such an assessment dur-ing clinical care?

METHODS

A process for developing literacy-appropriate materi-als for patients ( Seligman et al., 2007 ) was adapted to engage a range of stakeholders in two Magnet-designated Midwestern hospitals ( American Nurses Credentialing Center, 2016 )—one academic and one community based. Between June and November 2015, we solicited input during clinical meetings, facilitated an intensive, daylong workgroup, and conducted a series of interviews with expert clinician and patient stakeholders (see Figure 1 for develop-ment activities and participants). The workgroup of rural stakeholders was audio-recorded and tran-scribed verbatim, and detailed notes were taken dur-ing all other encounters. Data analysis was a continu-ous, iterative process, undertaken after each meeting. Each research team member (ASW, TP, ED) com-pleted their own thematic analysis, after which the team arrived at collective themes. These themes were then confi rmed during follow-up meetings with aca-demic and community-based stakeholders. The study was approved by the University of Iowa and Mercy-Clinton Community Institutional Review Boards.

Convene a Working Group and Solicit Early Input

The project started in the academic medical center, where its purpose was presented during three meet-ings; two with staff nurses and one with clinical lead-ership. Preliminary content areas (e.g., areas where patients appear to have diffi culty and communica-tion gaps between members of the clinical team) were identifi ed through soliciting specifi c ideas about how experiences with the D -CEGRM could apply to the hospital discharge process.

On the basis of preliminary discussions, the research team (nurse-investigator, health infor-maticist) convened a larger development team that involved partnerships between the academic-based research group (that also expanded to a graphic designer and graduate nurse research associate) and community-based stakeholders (nurse administrators in a community-based acute care hospital, or “com-munity-based research group”). Key nurse leaders from a rural, community-based hospital were con-tacted via phone upon multiple occasions to assess their needs related to discharge planning and patient care transitions from hospital to home. A workgroup



was eventually established within the community-based hospital that included those involved in past and current efforts to improve nurse-delivered dis-charge education. The fi nal workgroup consisted of 14 health care providers including staff nurses charged with direct patient care (4), health coaches charged with follow-up and in-home interviews (2), a patient advocate (1), nurse practitioner directing a care transitions program (1), medical-surgical case manager overseeing discharge process changes (2),

social worker involved with discharge processes of complex patients (1), care management director (1), medical-surgical nurse manager (1), and clinical nurs-ing supervisor (1).

Identify Key Concepts

At the rural, community-based hospital, a daylong meeting with the workgroup was held to refi ne con-crete plans for assessing social support as part of

FIGURE 1 Development activities.



discharge planning. Experiences with the D- CEGRM were shared with this group. A particular focus of this workgroup was to elicit details of how a social support assessment would fi t into clinical workfl ow—something that would be useful, address known gaps in social support, and for what patient populations (e.g., high-risk only, all patients). In-depth ques-tions were asked regarding current discharge plan-ning processes, how members of clinical teams get a sense of patients’ home context, how each profes-sional obtains knowledge of a patient’s home context if they had never encountered the patient, barriers to successful care transitions, when the patient gets involved (if at all), and what the individual compo-nents of an assessment should include.

Map Concepts to Behavioral Theory

To inform future development and evaluation efforts, the next step in the development process was to explore and map our efforts to a behavioral theory. Although the original CEGRM was informed by social network theory, it was clear from our contact with stakeholders that an assessment of social support was seen as part of supporting patients’ self-manage-ment after hospital discharge. As such, the research team explored self-management theories and found that the Individual and Family Self-Management The-ory, IFSMT ( Grey, Knafl & McCorkle, 2006 ; Ryan & Sawin, 2009 ), best explicated how a social support assessment would facilitate self-management.

In the IFSMT, a key characteristic of self-man-agement is the purposeful engagement in, and per-formance of, learned behaviors by both individu-als and families ( Lorig et al., 1999 , 2001 ; Ryan & Sawin, 2009 ). Self-management involves “knowledge and beliefs, self-regulation skills and abilities, and social facilitation to manage chronic conditions or engage in healthy behaviors.” Social facilitation is a key component in the process of patient self-manage-ment, with the patients’ context of risk and protective factors infl uencing facilitation. The emerging toolkit, based on the CEGRM, was conceptualized by the team as facilitating communication between patients and health care providers about patients’ context of risk and protective factors that infl uence social facili-tation (or lack thereof) of self-management upon dis-charge (see Figure 2 ).

Carefully Design Materials Using Low Literacy Principles

To facilitate reading ease, a large font, logical fl ow of information, headers to introduce the reader to each topic, adequate space to take notes on each page (if desired), and a simple content page was used. Pictures

were carefully chosen to emphasize key topics and represent multiple target populations. Members of the research team spent time physically cutting and pasting pictures, words, and pages, and multiple drafts were presented to the instructional designer for reconstruction.

Refi ne Materials

Rough drafts of Toolkit were shown to health care professionals at the rural, community-based hospi-tal, members from a Patient Advisory Council from the academic medical center, and expert nurses in the academic health sciences center to obtain opinions, recommendations, and clarifi cation of concepts from those unassociated with the development process. On the basis of impressions from these individuals, the toolkit, then named the “Going Home Toolkit” (GHT), was revised with a graphic designer. This was an important step to determine the visual appeal, understandability, and potential usefulness of the GHT from an audience not invested in the develop-ment process.

Assess in Target Audience

The last stage of Toolkit development was to ask staff nurses naïve to the GHT and its purpose to use the GHT during routine clinical care. Three staff nurses were recruited to pilot the fi nalized copy of the GHT. Members of the research team (AW, TP, ED) met with the participating nurses on the day of testing to intro-duce them to the GHT, solicit initial impressions, and observe how the nurses decided to use the Toolkit

FIGURE 2 The Going Home Toolkit and the IFSMT.



with their patients. The team explained that they were there to observe them pilot the Toolkit—that they wanted to see how the staff nurses would use it and integrate it into their workfl ow. Nurses were provided with examples of how they might use the toolkit, including going through the Toolkit page-by-page with the patient, involving family on discus-sion of resources, or simply introducing the GHT and leaving it at the bedside. It was emphasized that method of delivery was solely up to them. However, the research group emphasized that the initial idea behind developing the GHT, based on the ISFMT the-oretical framework, was to provide a tool to engage the patient in the discharge planning, focusing spe-cifi cally on social support needed to facilitate their efforts to self-manage their condition after discharge.

RESULTS

Early Input and Key Concepts

During initial interviews, academic clinicians endorsed the need to incorporate more social infor-mation into risk assessments and in discharge plan-ning itself. After the research team explained their experiences with the CEGRM, and a vague vision for how such a tool might be used to assess patients’ support networks and inform anticipatory planning for discharge, academic health care providers stated that such an assessment would need to be straight-forward for providers, but also engage patients. Even though, at times, it was brought up that discharge planning for high-risk groups or consultations by licensed social workers/case managers appeared suf-fi cient for successful hospital-to-home transitions, social support was not systematically assessed and known to the health care teams. The only proxy for social support, particularly for patients not previ-ously identifi ed as high-risk or who were unknown to the staff (e.g., patients hospitalized a fi rst myocar-dial infarction), was whether a patient had an emer-gency contact listed. The clinical nurses, in particular, agreed that they had to “dig” in the medical record

to fi nd any information about social support and/or discharge plans. They unanimously agreed that there was a great need for a resource to identify and address social risk factors and discharge needs in allpatients, not only those in populations known to be at high risk for poor outcomes postdischarge.

Academic-based clinical nurses and discharge coordinators (nurses and social workers) communi-cated a desire to use technology with the GHT for two reasons: because of how it might facilitate com-munication without taking the time of already busy clinicians, and to enable capture of psychosocial information and incorporate it into electronic health records. However, clinicians questioned the ability of many in the targeted demographic (older adults who are ill) to interact with technology. They stated that their target population would need a “paper type” assessment, and that a hard-copy version might also be valuable to patient families by providing a visual artifact of planned resources. It was also mentioned that having both options—paper version and com-puter application—might eventually be helpful. The providers offered numerous suggestions for the implementation of in both paper and electronic for-mats. The ideas for the paper version were primarily a booklet with areas for patient and provider nota-tion, or a set of cards, with each card specifi c to an area of support (e.g., transportation, shopping, and medications). The electronic suggestions ranged from a simple electronic tablet application that mirrored the paper version, to more complex tools, such as an electronic “drop box” that would augment the elec-tronic medical record with color-coded visual ques-tions indicating areas of postdischarge support that were still needed for the patient.

As a result, the visual design of the GHT form used for the study (paper) could be used as a low-fi delity human factors prototype ( Sefelin, Tscheligi, & Giller, 2003 ; Snyder, 2003 ; Walker, Takayama, & Landay, 2002 ) that might be more easily translated into other modalities (eg, tablets and smart devices), with a higher level of human-centered design ( Tory & Moller, 2004 ) and human interface consistency to

The research group emphasized that the initial idea behind developing the GHT, based on the ISFMT theoretical framework, was to provide a tool to engage the patient in the discharge planning, focusing specifi cally on

social support needed to facilitate their efforts to self-manage their condition

after discharge.

Even though, at times, it was brought up that discharge planning for high-

risk groups or consultations by licensed social workers/case managers

appeared suffi cient for successful hospital-to-home transitions, social

support was not systematically assessed and known to the health care

teams.



provide seamless transition by providers between dif-ferent platforms upon which GHT might be imple-mented. Such an approach would make the GHT more resilient to provider heterogeneousness by pro-viding reduced training and support, increased pro-ductivity, and improved acceptance ( Maguire, 2001 ). Thus, the toolkit would be appealing to a larger pro-vider base.

Input from the rural, community-based work-group identifi ed many challenges when attempting to prepare patients for discharge to rural communities. Workgroup members identifi ed obtaining medica-tions, transportation to appointments, variability in staff nurse experience and practice, inability to indi-vidualize discharge education templates, and inability of primary care providers to obtain discharge paper-work as major barriers to providing high-quality discharge plans to rural patients. The case manag-ers stated that they attempt to have patients fi ll their medications at the hospital prior to discharge to avoid problems, and to address transportation needs by scheduling taxi services to pharmacies or appoint-ments. However, the workgroup stated that discharge instructions include a lot of information that cannot be individualized to patient needs. Multiple partici-pants involved in delivering care in community-based settings, or new care transitions programs, reported using their own templates for medication manage-ment (e.g., name of medication, why it is taken, dose, and schedule) because they felt the layout of the instructions was often too diffi cult for patients to interpret. Elements they identifi ed as important to include in a Toolkit included details about follow-up appointments, transportation methods (for discharge, appointments, groceries, prescription pick-up), who patients may contact at local pharmacies, tools to help interpret worsening symptoms (i.e., color zones to help patients identify signs and symptoms of heart failure/chronic obstructive pulmonary disease), and sources support for self-care (e.g. dressing changes and ambulation) after discharge.

Everyone in the workgroup agreed the staff nurses are the clinicians most often identifying patient needs and interventions around discharge. However, the nurses stated that every nurse is dif-ferent in how much effort they put into discharge planning. For example, one nurse stated that “you can ask one nurse and she can tell you the home liv-ing situation, what happened in the last three weeks, but ask another, and they’ll be like, ‘They came from the ED (emergency department).’” In this way, the group believed that a social support assessment might address variability in understanding the social con-text of patients, and be especially helpful for novice nurses who may not be “seasoned” enough to ask the right information of patients.

Workgroup members expressed that any new intervention needed supplement or supplant, not duplicate, current efforts. One concern was that the staff nurses would not have time to help the patient fi ll out as assessment like the D -CEGRM, so the workgroup confi rmed preliminary input from aca-demic-based nurses and managers about how a tool-kit might be crafted as a patient-completed resource. In this way, the patient could be engaged in their own care by way of identifying their own transitional care needs, and concretely communicating those needs with multiple members of the health care team and, perhaps, to their personal support resources (e.g., family and friends). However, after agreeing that patients and families would be key to completing the information, the community-based workgroup also questioned the feasibility of having patients to complete such an assessment using technology (e.g., tablet computers and smartphones).

Finally, discussion in the workgroup revealed incorrect assumptions of what others do in the dis-charge process, and how important discharge infor-mation is transferred between team members, and between team members and patients/families. Par-ticipants realized the existence of these communi-cation gaps during the workgroup discussion, how lapses in communication likely lead to discontinuity of discharge coordination, and the need for a tool to ensure that communication about resources needed for patient self-management (e.g., transportation, assistance with medication administration, or ques-tions) should be used. As a result, the workgroup envisioned a Toolkit being used by all team members and to provide a visual artifact for both providers and patients.

Designing and Refi ning Materials

After distilling common themes across the groups of academic- and community-based stakeholder groups, and identifying the IFSMT framework (through which mechanisms for how the proposed Toolkit might improve patient outcomes were identifi ed), current tools (all hard copy) used to facilitate dis-charge planning in the academic medical center were surveyed by members of the research team (ASW, TP, ED). Academic nurses familiar with both current and past discharge planning tools reported that they were not currently used by staff, identifying that the purpose of the tools have been vague, the value was not apparent and, if there was any benefi t to patients, it was never communicated to staff. Nurses commu-nicated that the current discharge planning tool was simply “a piece of paper with questions” that was lost in the piles of other discharge paperwork. It was also observed that the content covered was written



at a high literacy level, was lengthy, and not visually appealing enough, making it unlikely that patients themselves would be able to self-complete the form.

Additional input from expert nurses generated ideas for additional content, improvements, and sus-tainability. Some examples included developing the Toolkit into an electronic resource with potential for prepopulating/tailoring with resources in patients’ home community, the need to understand whether the Toolkit may facilitate therapeutic relationships between nurses and patients away from task orienta-tion (“give nurses permission to care”), and whether it should be integrated as part of a “time-out” for providing discharge planning with patients, much like safe practices related to medication administra-tion, to emphasize the importance of patients’ expe-riences and home context. Finally, nurses identifi ed two additional areas needing to be addressed in the Toolkit: (1) whether patients would be able to care for loved ones (e.g., children) or pets; (2) whether patients knew where to go with fi nancial concerns.

Based off collective feedback, and after itera-tive work with a graphic designer, the resulting “Going Home Toolkit (GHT)” was developed as a hard-copy tool. In a pragmatic sense, its structure was largely guided by identifying questions in exist-ing discharge planning tools (e.g., “Do you have a ride home?”) applicable to the key content identi-fi ed by participants and stakeholders (e.g., trans-portation), and making questions patient centered and low literacy (“Will I need help getting around?” “How will I get home?” “How will I get to appoint-ments?”). The research team, with the instructional designer, focused on clearly delineating what was identifi ed as key self-management “tasks” (e.g., tak-ing medication) from potential sources of support for those tasks (e.g., community pharmacist, visit-ing nurse, family, and neighbors). This was done to fulfi ll the need for the resource to be adaptable and self-reported by patients. Finally, a draft was presented to a patient advisory council meeting, where patients—representing a number of condi-tions and roles—endorsed the content of the Toolkit, and understanding of its purpose. After a few small

Academic nurses familiar with both current and past discharge planning

tools reported that they were not currently used by staff, identifying that

the purpose of the tools have been vague, the value was not apparent and, if there was any benefi t to patients, it

was never communicated to staff.

edits based off patient feedback (grammar, wording), the draft of the GHT was printed to test during dis-charge planning (see Figures 3–5 for photographs of the hard-copy “Going Home Toolkit.”)

Feasibility Test

Upon being introduced to the purpose of the pilot, staff nurses testing the GHT (n = 3) gave mixed per-ceptions of whether gaps in patients’ home living environments were adequately addressed and com-municated to all health care team members. One of the staff nurses thought the GHT included a lot of information that they cover already, and that they already had a good discharge process in place (with social workers and case managers identifying gaps in patients’ home context). One nurse stated that, per-haps, the GHT would capture what was being done regarding discharge in a way that patients could see, and expanded by proposing that the GHT might simultaneously facilitate communication across team members, stating that “dietary might fi ll out diet questions, and case management could fi ll in infor-mation about billing.”

One nurse commented that the medication page of the GHT was essential, and that there were a few things that they would not normally know or ask patients about, such as how they would get meals and run errands. One nurse enthusiastically stated that fi lling out the GHT would help patients “feel more cared for.” However, she also stated that there may be variability in patient receptivity—that the elderly might like it more, and others may not care to use it. When asked about whether or not current process for communicating discharge plans to patients was satis-factory, the nurses were hesitant to claim that it was, and agreed that the GHT may help accomplish this.

After being oriented, the three participating nurses were then observed testing the GHT with patients (n = 9). In all cases, after confi rming will-ingness of the part of patients to have the interac-tion observed by a member of the research team, par-ticipating nurses opted to (1) introduce the GHT to patients, stating that he overall purpose of the book was to help them plan for discharge; (2) show the con-tent page, highlighting the various needs addressed (personal transportation, medications, etc); and (3) go through each topic area and identify at least one personal resource. However, a key area of variabil-ity in administration was observed by all members of the research team: in some encounters, the GHT was used to guide extensive, open-ended exchanges between nurses and patients and, in some encoun-ters, nurses appeared to be fi lling in the resources on behalf of the patient rather than encouraging patients themselves to expand on their personal resources



(e.g., “Your husband drives you around, right?” “You have [name of pharmacy] set up.” Vs. “You will need help getting around when you go home, who do you have to help you with this?” “I know you have [name of pharmacy] listed on your records, do you feel ok about getting your medications there? Do you know where to call if you have questions?”). Variability in questioning style and patient circumstance likely explained variability in administration time, which ranged from 10 to 25 min. Patients exhibited no dif-fi culty reading and understanding any of the material presented, or participating in the conversations.

Although personal circumstances of patients were not included in this study, the research team observed, in three of the nine patient encounters, a change in process informed by GHT-guided conversations. Examples of these changes were procuring additional resources for home care, and changing listed pharma-cies. In six of the nine encountered, additional, detailed education was provided to patients about limitations they may face, and how that may impact their need for additional support, when they return home.

At the conclusion of the observation days, indi-vidual debriefi ng sessions were held with participat-ing nurses. All three stated that they felt the GHT was valuable, but saw that most value would be to patients themselves who would now have concrete means of tracking the activity, and members of, the discharge team. One nurse emphasized that she felt the current staffi ng for planning discharge (involving discharge coordinators) was adequate, but that the GHT would be helpful for multiple members of the team to make sure that patient needs are met. The nurse then proceeded to give an example that the GHT would allow for her to see—with the patient—that the patient was seen by dietary services, or by utilization management (for billing questions), and would allow her to reinforce any messages that were communicated.

All of the nurses acknowledged that the GHT was helpful in eliciting useful information from patients, but there remained questions about how it might be best deployed during clinical care. One nurse remained skeptical about whether it was useful to her

FIGURE 3 Sample Going Home Toolkit—contents page.



own practice of bedside nursing; she saw that what was being addressed in the GHT as more related to what “discharge coordinators and social workers do.” In contrast, one nurse emphasized that she felt

it was her responsibility, as the assigned nurse, to “know as much as possible about what’s going on with my patients” and that the GHT would assist with that, and make it clear how to other team members,

FIGURE 5 Sample Going Home Toolkit—personal care resource page.

FIGURE 4 Sample Going Home Toolkit—personal care-guided questions page.



patients, and families how she was contributing to the discharge process and make it clear to her what was left to be accomplished. The nurses remained inter-ested in the idea of whether the GHT would be helpful as a patient-completed resource. All three participants stated they would be willing to continue testing the GHT, but that they would likely only use it in specifi c patients; however, none of the participating nurses could provide a clear strategy for how they would tar-get individual patients/populations of patients.

DISCUSSION

In this study, we aimed to develop a tool that could more clearly identify and address patient resources supportive of their self-management efforts after hospital discharge. The development process focused on identifying factors supportive of patients’ self-management after discharge that might otherwise be unknown to health care providers, and methods for facilitating communication between patients and health care providers regarding patients’ current social resources supportive of self-management after dis-charge. A secondary aim of the development process, which evolved from stakeholder input, was to create methods for making the discharge planning process transparent across team members and patients.

Social support, although acknowledged as crucial to patient health and well-being after an acute hospi-talization, is not systematically assessed or addressed during routine care. However, the clinical realities of busy inpatient settings require that means of assess-ing social support require both a patient- and pro-vider-centered approach to allow for implementation and sustainability. By engaging stakeholders across academic and community-based clinical settings in an iterative development process, we uncovered a common need for addressing social support during the hospital discharge process in a way that facili-tated meaningful conversations, expansive thinking, and engagement in directed actions to facilitate self-management after hospital discharge (e.g., education and referrals by providers, planning, and self-care).

Social network researchers suggest that inter-views of personal networks can prompt individuals

to consider their interpersonal context, potentially making them aware of the contacts and ties they do and do not possess, which may infl uence outcomes. Such evidence suggests individuals may be prompted to create or act on personal ties simply by displaying network results ( Valente, 2012 ). This may be key for rural patients for whom it may be necessary to rely on networks outside formal health services to meet their self-management needs at home. Capturing these needs with a resource such as the GHT may not only help patients see their own needs, but would assist providers in identifying patients at risk for poor outcomes because of a lack of supportive resources so that proper interventions could be applied and poten-tial assistive resources provided.

Testing the hard-copy GHT with a small sample of staff nurses suggested the GHT utility: with little direction, nurses were able to use the book in a way that they believed informed their professional prac-tice by guiding additional education and resource planning. However, variability in how nurses used the GHT to guide interviews (e.g., fi lling in on behalf of patients vs. as part of an expansive conversation) and in their impressions of how it could best be inte-grated into clinical workfl ow (e.g., with discharge planners vs. with bedside nurses) will require addi-tional development work regarding implementation, and a thorough examination and incorporation of patient experiences, receptivity, and ideas.

The described development process is limited in several ways. First, although we attempted to involve a range of stakeholders across both academic and community-based settings, the collective experi-ences and opinions are limited to two settings in one state serving the needs of rural patients. For exam-ple, although there was a focus to understand how technology may be deployed as art of this effort, the culture of the two settings and impression about the patients served, and the desirability to have a user-centered human factors design necessitated that the Toolkit initially take form as a hard-copy resource. However, even in this setting where questions of connectivity and receptiveness arose, there was enthusiasm about the future role of technology to help deliver the GHT, and the GHT may take a very

By engaging stakeholders across academic and community-based clinical settings in an iterative development process, we uncovered a common need for addressing social

support during the hospital discharge process in a way that facilitated meaningful conversations, expansive thinking, and engagement in directed actions to facilitate

self-management after hospital discharge (e.g., education and referrals by providers, planning, and self-care).



different form in an environment with more techno-logical resources. Second, the small sample size of nurses testing the resulting Toolkit limits our abil-ity to generalize their experiences to a larger popu-lation of clinical nurses. However, even in this very small sample, the nurses communicated a range of impressions useful in planning future development and larger-scale testing efforts.

CONCLUSION

As evidenced by the literature and the input from this study’s stakeholder groups, the transitional care period is a vulnerable time for discharging patients. Whether they are at risk for readmission or not, patients have needs when going home that often go unmet. The described development process appears to support the idea that providing a visual tool (Going Home Tool-kit—GHT) to engage health care team members and patients in important conversations about patients’ home environments may reveal gaps in self-manage-ment support. The GHT may uncover information critical to discharge planning about which health care providers and, potentially, even patients themselves are unaware. A health care provider from the commu-nity-based stakeholder workgroup said it best:

We’re not good at fi nding those at risk for readmis-sion. There’s that black box of people we’re missing. It is better to identify those people at risk earlier [with a tool like the GHT] … . Every patient should engage in this [GHT process], to give them a take-away.

The iterative process of developing a hard copy of the GHT was one of concept confi rmation, dis-covery, and knowledge enhancement of transitional care barriers and provider perceptions, assump-tions, and recommendations. Through the develop-ment and pilot testing of the GHT, it was confi rmed that such a tool designed to identify home going needs and engage all team members (including the patient) in discharge planning is not only feasible but necessary.

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Andrea Wallace, PhD, RN, is an Associate Professor at the Uni-versity of Utah College of Nursing and School of Medicine. Dr. Wallace’s clinical research focuses on narrowing gaps in health outcomes for those living with chronic illnesses while understanding how interventions can be feasibly administered during routine service delivery.

Todd Papke, PhD, is a Technology Innovations Scientist at the Uni-versity of Iowa College of Nursing. He serves as a technology consultant in both research and education initiatives, and focuses on improving data aggregation, reporting, and research processes as part of the Evidence-Based Practice and Quality group at UIHC.

Erica Davisson, MSN, RN, is a PhD candidate, research assis-tant, and guest lecturer at the University of Iowa. In addition, she contin-ues to work part-time as a staff nurse at UIHC. Ms Davisson’s research focuses on staff nurses’ decision making during discharge planning for patients with heart failure.

Kara Spooner, MSN, is Medical Surgical Nursing Unit Director at Mercy Medical Center, Clinton, Iowa. In that role, she builds on 12 years of nursing experience. Prior to her role as a unit director, she worked as a Clinical Development Specialist assisting with nursing orientation and educational opportunities for staff.

Laura Gassman, MHA, BSN, RNC-EFM, serves as Director of Clinical Professional Development, Quality and Magnet Coordinator at Mercy Medical Center. In these positions, she leads teams who provide curriculums for leadership, clinical mastery, infection prevention, and metric-driven outcomes. She has been instrumental in facilitating simu-lation education, research studies, advancement programs, and Magnet designation.

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DOI: 10.1097/NCM.0000000000000247


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CE 1.5 ANCC Contact Hours Vol. 22 , No. 5 , 214 - 227