Reducing readmission and ED utilization rates is central to health care improvement and reform efforts (Naylor et al, 2011). Recent research has linked hospital nurse staffing to readmission rates (McHugh et al., 2013; Weiss et al., 2011). With Medicare readmission rates approaching 20% (Jencks et al., 2009) and financial penalties for high rates of 30 day readmission, novel approaches to engaging hospital nurses in readmission reduction efforts hold significant promise for promoting high-quality affordable patient care.

Problems with hospital discharge are well documented. Perceived inadequacies in discharge planning, teaching, and coordination are associated with greater likelihood of postdischarge problems, ED use, and readmission (Banja et al., 2007; Bull et al., 2000; Coleman et al., 2005; Henderson & Zernicki, 2001; Jack et al, 2009). Most readmissions within 30 days are viewed as preventable (Medpac, 2007) and failures of discharge preparation (Minott, 2008).

Large scale initiatives to improve discharge transitions have focused on communication and coordination of care between hospital and community providers using specialized roles for transition support (Coleman et al., 2006; Jack et al., 2009; Naylor et al., 1999, 2004, Nielsen et al., 2008). The role of the acute care staff nurse has been virtually ignored in discharge transition initiatives, despite the fact that, in most hospitals, the staff nurse is responsible for the complex processes of preparing patients for discharge (Foust, 2007; Nosbusch, Weiss, & Bobay, 2011).

Readiness for discharge is an outcome of discharge preparation. In previous research by this study team, the 21-item Readiness for Hospital Discharge Scale (RHDS) has been developed and tested with multiple inpatient groups (Weiss et al., 2006, 2007, 2008, 2009; Lerret & Weiss, 2011). In measuring readiness for discharge to home following adult medical-surgical hospitalization, patient self-report [PT-RHDS] and nurse assessment [RN-RHDS] forms of the scale have demonstrated an association with post-discharge utilization (readmissions and ED visits) (Weiss et al., 2007, 2010, 2011). The RHDS was reduced to an 8-item version for use in clinical practice. The 8-item RN-RHDS was more strongly associated with readmission than the 8-item PT-RHDS in 2 adult samples in the Midwest and Eastern US (Weiss et al., 2010; Weiss et al, in review). Patients with low readiness by nurse assessment experienced more than a 6-fold increase in the likelihood of being readmitted (Weiss et al., in review).

Currently there is no standard approach or tool available for routine use in clinical practice. The body of evidence from prior studies by the research team lays the foundation for the recommendation that pre-discharge readiness assessment be implemented as a standard nursing practice (Weiss et al., 2011).

Previous studies by the READI study team:

Holland, D.E., Vanderboom, C.E., Delgado, A.M., Weiss, M.E., Monsen, K.A. (2016). Describing pediatric hospital discharge planning care processes using the Omaha System.  Applied Nursing Research, 30,24-28.             

Mabire, C., Coffey, A., & Weiss, M. (2015). Readiness for Hospital Discharge Scale for Older People: development and psychometric testing from three countries. Journal of Advanced Nursing, 71(11),2686–2696.

Weiss, M.E, Bobay, K.L., Bahr, S., Costa, L., Hughes, R., & Holland, D.E. (2015).  Discharge preparation: A model for hospital discharge transition care. Journal of Nursing Administration, 45(12), 606-614.

Bobay, K.L., Bahr, S., Weiss, M.E., Hughes, R., Costa, L.  (2015).  Models of discharge care in Magnet hospitals. Journal of Nursing Administration, 45(10):485-491.

Lerret, S. M., Weiss, M. E., Stendahl, G., Chapman, S., Menendez, J., Williams, L., Nadler, M., Neighbors, K., Amsden, K., Cao, Y., Nugent, M., Alonso, E., & Simpson, P. (2015). Pediatric Solid Organ Transplant Recipients: Transition to Home and Chronic Illness Care.  Pediatric Transplantation, 19 (1), 118-129.  

Yakusheva, O., Lindrooth. R., & Weiss, M.E. (2014). Nurse value-added and patient outcomes in acute care. Health Services Research, 49(6), 1767–1786.

Yakusheva, O., Lindrooth. R., & Weiss, M.E. (2014). Economic evaluation of the 80       percent baccalaureate nurse workforce recommendation: a patient-level analysis.     Medical Care. 52(10), 864-869.

Lerret, S. M., Weiss, M. E., Stendahl, G., Chapman, S., Neighbors, K., Amsden, K., Lokar, J., Voit, A., Menendez, J., & Alonso, E. (2014).  Transition from Hospital to Home Following Pediatric Sold Organ Transplant: Qualitative Findings of the Parent Experience.”  Pediatric Transplantation, 18, 527-537.

Weiss, M.E., Costa, L., Yakusheva, O., & Bobay. K. (2014). Validation of patient and nurse short forms of the Readiness for Hospital Discharge Scale and their relationship to return to the hospital. Health Services Research, 49(1), 304-317.

Scala, E., & Costa,  L. (2013). Using appreciative inquiry during care transitions: an exploratory study. Journal of Nursing Care Quality.   May 31. [Epub ahead of print].

Vartanian. H., Bobay, K.L., Weiss, M.E. (2013). Nurses perceptions of sustainability of magnet efforts. Journal of Nursing Administration, 43(3), 166-171.

Lerret, S. & Weiss, M.E. (2011). How ready are they? Parents of pediatric solid organ transplant recipients and the transition from hospital to home following transplant. Pediatric Transplantation,15,606–616 DOI: 10.1111/j.1399-3046.2011.01536.x.

Weiss, M., Yakusheva, O., & Bobay, K. (2011). Nursing staffing, readiness for hospital discharge, and post-discharge utilization. Health Services Research, 46(5), 1473-1494. 

Bobay, K., Yakusheva, O., & Weiss, M.  (2011). Outcomes and cost analysis of the impact of unit-level nurse staffing on post-discharge utilization. Nursing Economics, 29(2), 69-78, 87.

Nosbusch, J.M., Weiss, M.E., & Bobay, K.L.  (2011). An integrated review of the literature on challenges confronting the acute care staff nurse in discharge planning. Journal of Clinical Nursing, 20(5-6), 754-774. 

Costa, L., Poe, S. & Lee, M.  (2011). Challenges in posthospital medication management: Nurses as coaches for medication management.  Journal of Nursing Care Quality,  26(3): 1-9

Bobay, K., Jerofke, T, Weiss, M., & Yakusheva, O.  (2010). Age-related differences in perception of quality of discharge teaching and readiness for hospital discharge. Geriatric Nursing, 31(3), 178-187.

Weiss, M.E., Yakusheva, O, & Bobay, K.L.  (2010). Nurse and patient perceptions of discharge readiness in relation to post-discharge utilization. Medical Care, 48(5), 482-486.

Weiss, M.E. & Lokken, L. (2009). Predictors and outcomes of postpartum mothers’ perceptions of readiness for discharge after birth.  JOGNN, 38, 406-417.

Miller, J.M., Piacentine, L.B., & Weiss, M. (2008). Coping difficulties after hospitalization.  Clinical Nursing Research, 17(4), 278-296.

Maloney, L.R. & Weiss, M.E.  (2008). Patients’ perception of hospital discharge informational needs.  Clinical Nursing Research, 17. 200-219.

Weiss, M., Johnson, N., Malin, S., Jerofke, T., Lang, C ., & Sherburne, E. (2008). Readiness for discharge in parents of hospitalized children.  Journal of Pediatric Nursing, 23(4), 282-295.

Weiss, M.E., Piacentine, L.B., Lokken, L., Ancona, J., Archer, J., Gresser, S., Holmes, S.B., Toman, S., Toy, A., & Vega-Stromberg, T. (2007). Perceived readiness for hospital discharge in adult medical-surgical patients. Clinical Nurse Specialist, 21, 31-42.

Weiss, M.E. & Piacentine, L.B.  (2006). Psychometric properties of the Readiness for Hospital Discharge Scale.  Journal of Nursing Measurement, 14(3), 163-180.