Key Points Question What is the effect of adding structured nurse assessment of patient readiness for discharge to standard medical-surgical unit discharge practices on 30-day return to hospital? Findings In this multisite cluster randomized clinical trial, when patient self-assessments were combined with readiness assessment by nurses, high-readmission units showed a reduction in 30-day hospital returns. Mixed results were observed for nurse assessments only and for low-readmission units. Meaning Adding a structured discharge readiness assessment by the discharging nurse that includes patient self-assessment to standard practice for hospital discharge may reduce readmissions and emergency department or observation visits.

Aim The aim is to clarify the use of the term continuity in the specific context of acute care hospitalization and discharge. Background The meaning of “continuity” is often co‐mingled with other concepts, specifically coordination and communication. To increase usefulness for contemporary concerns with the hospitalization‐postdischarge continuum, continuity of care is examined from the specific context of acute hospitalization and discharge. Design Concept analysis. Data Sources Medline via Ovid, Cochrane Library, Cinahl, and Google Scholar. Search years encompassed 2001–2016. Review Methods Rodgers evolutionary concept analysis method. Results A total of 50 papers were included in this concept analysis. Synthesis of findings from these papers resulted in a model of continuity of care that illustrates the hierarchical and interdependent relationship between time and setting, patient‐provider relationships, communication, and coordination in the context of discharge transitions. Conclusion The continuity model provides a framework to assist in the design of multicomponent, interdisciplinary, integrated interventions that can then be tested for their effect on patient care practices and outcomes.

There has been a proliferation of initiatives to improve discharge processes and outcomes for the transition from hospital to home and community-based care. Operationalization of these processes has varied widely as hospitals have customized discharge care into innovative roles and functions. This article presents a model for conceptualizing the components of hospital discharge preparation to ensure attention to the full range of processes needed for a comprehensive strategy for hospital discharge.

This systematic review of the literature assessed the impact of a postdischarge telephone call on patient outcomes. Nineteen articles met inclusion criteria. Data were extracted and an evidence table was developed. The content, timing, and professional placing the call varied across studies. Study strength was low and findings were inconsistent. Measures varied across studies, many sample sizes were small, and studies differed by patient population. Evidence is inconclusive for use of phone calls to decrease readmission, emergency department use, patient satisfaction, scheduled and unscheduled follow-up, and physical and emotional well-being. Among these studies, there was limited support for medication-focused calls by pharmacists but no support for decreasing readmission. Health care providers benefited from feedback but did not need to place the call to realize this benefit. Inpatient nurses were unable to manage the volume of calls. There was no standardized approach to the call, training, or documentation requirements.

The Consolidated Framework for Implementation Research guided formative evaluation of the implementation of a redesigned interprofessional team rounding process. The purpose of the redesigned process was to improve health team communication about hospital discharge. Themes emerging from interviews of patients, nurses, and providers revealed the inherent value and positive characteristics of the new process, but also workflow, team hierarchy, and process challenges to successful implementation. The evaluation identified actionable recommendations for modifying the implementation process.