Results Summary
What was the research about?
When patients go home after a hospital stay, they may still need help. Having support is important to help patients recover and prevent them from having to go back to the hospital. Patients may not know how to plan follow-up care or get help from community organizations. Patients who live in rural areas may have a hard time getting support close to where they live.
In this study, the research team compared a group of patients receiving standard support with a group in a new program. The new program was designed to support people living in rural areas when they go home from the hospital. The team looked to see if patients in the new program went back to the hospital less than those who weren’t in the program.
What were the results?
In the first 30 days after going home, patients in the new program had fewer hospital stays than those who weren’t in the program.
The two groups didn’t differ in
- The number of emergency room, or ER, visits
- The number of patients with at least one hospital stay or ER visit
- Physical or mental health
- The number of times patients went to their doctor after going home
- How patients rated the quality of the support they received from the hospital
Who was in the study?
The study included 127 patients living in four rural counties in Montana. Of these, 87 percent were white, and 10 percent were American Indian or Alaska Native. The average age was 61, and 57 percent were men.
What did the research team do?
The research team created the new program to help patients who live in rural areas when they go home from the hospital. Hospital staff helped patients in the program figure out what they would need at home while they were recovering, such as help with cleaning or buying groceries. Then staff helped patients find resources near home to meet these needs. Staff also helped patients schedule follow-up doctor visits and manage their care across different doctors.
For patients receiving usual support, staff helped arrange transportation home and gave basic guidance for self-care and taking medicine once they were home.
During the first three months after leaving the hospital, the research team gave patients eight surveys about the support they received. The team also looked at patients’ health records.
Patients, doctors, and hospital staff helped design the study.
What were the limits of the study?
The study only included patients ages 18 to 75. Results may differ for patients older than 75. The study took place in one state and most patients in the study were white. Results may differ for people in other states or from other racial and ethnic backgrounds.
Future research could look at other ways to help patients in rural areas when they go home from the hospital.
How can people use the results?
Hospitals can use these results when thinking about ways to support patients in rural areas when they leave the hospital.
Professional Abstract
Objective
To evaluate the effectiveness of a hospital discharge planning program designed for patients living in rural areas on reducing readmissions and emergency department (ED) visits compared with usual discharge planning services
Study Design
| Design Element | Description |
|---|---|
| Design | Quasi-experimental study |
| Population | 127 adults ages 18–75 living in rural areas of Montana who had at least one overnight hospital stay |
| Interventions/ Comparators |
|
| Outcomes |
Primary: number of hospital readmissions, number of ED visits, proportion of patients with at least 1 hospital admission or ED visit during the first 30 days following discharge Secondary: number of primary care visits in the first 90 days after discharge, functional and mental health, patient-reported quality of discharge planning and services, patient perspectives on delivery of rural transition services |
| 30-day postdischarge follow-up for primary outcomes |
This quasi-experimental time series study compared the effectiveness of the Rural Options At Discharge Model of Active Planning (ROADMAP) program with usual discharge planning services on reducing readmissions and ED visits.
Researchers created the ROADMAP program to support patients who live in rural areas after hospital discharge. Researchers enrolled patients receiving care at regional hospitals in four counties on a rolling basis. At the start of the study, hospitals in each county provided usual services. During the study period, the researchers introduced the ROADMAP program in one county at a time.
In the ROADMAP program, hospital staff conducted an assessment of patients’ postdischarge needs. Based on this assessment, hospital staff provided resources to support patients as they transitioned home, such as help with cleaning or grocery shopping. Staff also coordinated care between regional and local healthcare providers.
For patients receiving usual discharge planning services, hospital staff provided a treatment and medication summary and standard educational materials about postdischarge treatment and self-care. Staff also helped arrange patients’ transportation home.
The study included 127 patients living in rural areas of Montana. Of these, 87% were white, and 10% were American Indian or Alaska Native. The average age was 61, and 57% were male.
Patients completed a survey to assess study outcomes at enrollment and seven more times during the 90-day period after discharge. Researchers also looked at patients’ electronic health records to collect demographic information and assess risk factors for hospital readmission.
Patients, physicians, discharge planners, and hospital administrators helped design the study.
Results
In the first 30 days after discharge, patients in the ROADMAP program reported fewer readmissions (p=0.05) compared with those receiving usual services. However, the two groups did not differ significantly in the proportion of patients with at least one readmission or ED visit or the number of ED visits reported. Patients in the ROADMAP program and those receiving usual services also did not differ significantly in any secondary outcomes.
Limitations
The study only included patients ages 18 to 75. Results may differ for patients older than age 75. The study took place in one state and most patients in the study were white. Results may differ for people in other states or from other racial and ethnic backgrounds.
Conclusions and Relevance
Patients who participated in the ROADMAP program reported fewer total readmissions in the first 30 days after discharge. Other measures, including the total number of ED visits and the proportion of patients reporting any hospital readmissions and ED visits did not differ between patients in the program and those receiving usual services.
Future Research Needs
Future research could explore other ways to improve discharge services for patients living in rural areas.
Final Research Report
View this project's final research report.
More About This Research
PCORI Stories
In Care Transitions, a Chance to Make or Break Patients' Recovery
Read a feature story about what happens when patients are harmed by poorly executed transitions between healthcare settings.
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- Reviewers said they would have appreciated additionale context about rural discharge processes and outcomes that could be collected with qualitative methods. The researchers noted that they collected 50 case studies using qualitative methods but did not include them in the report because this would add considerably to the report’s length.
- Reviewers commented on the smaller than expected enrollment as a weakness that was not well addressed in the report. They stated that it would have been helpful to understand the reasons why individuals declined participation. The researchers expressed disappointment in the low enrollment levels as well but noted the high retention rates. They added that the project’s human subjects protection committee deemed it inappropriate to press patients for an explanation when they chose not to participate.
- Reviewers commented that the measures used for the study outcomes lacked the sensitivity to detect change. The reviewers agreed and commented on this in their study limitations section.
- Reviewers asked for an explanation for why the researchers excluded patients older than 75 from the study, finding this exclusion especially problematic since older patients are an important segment of the hospital population. The researchers said that members of the research group and their advisors debated extensively about this decision. They chose to exclude older patients to limit the number of subjects with cognitive impairments, but in retrospect, the researchers said they believe they should have set a higher age cutoff.
- In a few cases, reviewers asked for details about analyses and outcomes that the researchers could not provide because not all notes remained available after office moves and closures.
Conflict of Interest Disclosures
View the COI disclosure form.
Journal Citations
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- Reviewers said they would have appreciated additionale context about rural discharge processes and outcomes that could be collected with qualitative methods. The researchers noted that they collected 50 case studies using qualitative methods but did not include them in the report because this would add considerably to the report’s length.
- Reviewers commented on the smaller than expected enrollment as a weakness that was not well addressed in the report. They stated that it would have been helpful to understand the reasons why individuals declined participation. The researchers expressed disappointment in the low enrollment levels as well but noted the high retention rates. They added that the project’s human subjects protection committee deemed it inappropriate to press patients for an explanation when they chose not to participate.
- Reviewers commented that the measures used for the study outcomes lacked the sensitivity to detect change. The reviewers agreed and commented on this in their study limitations section.
- Reviewers asked for an explanation for why the researchers excluded patients older than 75 from the study, finding this exclusion especially problematic since older patients are an important segment of the hospital population. The researchers said that members of the research group and their advisors debated extensively about this decision. They chose to exclude older patients to limit the number of subjects with cognitive impairments, but in retrospect, the researchers said they believe they should have set a higher age cutoff.
- In a few cases, reviewers asked for details about analyses and outcomes that the researchers could not provide because not all notes remained available after office moves and closures.