title: Standardizing hospital discharge planning at the Mayo Clinic.
abstract: BACKGROUND
  Improving the quality of patient coordination in the transition from hospital to home is a high-priority health care concern. The Centers for Medicare & Medicaid Services (CMS) Hospital Conditions of Participation in the Medicare Program require that hospitals have a discharge planning (DP) process in effect that applies to all patients. The impact of a practice change in DP practice on the quality of care coordination at discharge was evaluated from patients' perspectives.
  
  
  METHODS
  A multifactor, evidence-based DP practice change, which included merging of DP specialist roles and use of an early screen for DP decision support tool, was initiated in a large, Midwestern academic medical center and evaluated in a nonequivalent comparison group design with separate pre- and postpractice change samples. The three-item Care Transitions Measure (CTM-3) was mailed to adults recently discharged from one medical and one surgical nursing unit before and after the practice change.
  
  
  RESULTS
  Response rates were 52.4% before (218/416) and 39.5% (153/387) after the practice change. There were no significant differences between characteristics of the pre- and postpractice change participants. The mean CTM-3 score of patients who received assistance from the nurse/ social worker DP team improved by 14 points (67.2 to 81.2), although the data were skewed with a ceiling effect, rendering the results inconclusive.
  
  
  CONCLUSIONS
  Although the CTM-3 results were inconclusive, the practice change resulted in a clinically meaningful decrease in length of stay for a group of older patients at greater risk for complex discharge plans. The proactive approach to DP proved to be a valuable shift. The successes of the standardization of DP processes and improved multidisciplinary teamwork were important considerations for implementation throughout the organization.
authors.affiliation: Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA. holland.diane@mayo.edu
authors.forename: Diane E
authors.initials: DE
authors.lastname: Holland
authors.forename: Michele A
authors.initials: MA
authors.lastname: Hemann
mesh_terms: D000046:Academic Medical Centers / Q000458:organization & administration* / Q000592:standards; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care / Q000458:organization & administration* / Q000592:standards; D003661:Decision Support Techniques; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000458:organization & administration; D017060:Patient Satisfaction; D011787:Quality of Health Care / Q000458:organization & administration* / Q000592:standards