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The discharge summary is crucial as it enables a smooth transition from a healthcare facility to a patient's home or another care setting. This critical document facilitates seamless continuity of care, ensuring patients receive the necessary support and attention.
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Planning Nursing Care I01:21

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Related Experiment Video

Updated: Sep 22, 2025

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit
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Post-Hospital Availability of Instrumental Support May Influence Patients' Readiness for Discharge.

Beth E Schultz1,2,3,4, Cynthia F Corbett1,2,3,4, Ronda G Hughes1,2,3,4

  • 1Beth E. Schultz, PhD, DNP, RN, is a recent PhD graduate and her research activities focus on instrumental support related to home recovery and health care in the camp setting. She is currently working on research related to fatigue for camp staff and the impact of COVID-19 in the camp setting.

Professional Case Management
|May 26, 2022
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Summary

Registered nurse assessments of patient instrumental support are linked to reduced unplanned acute care use post-discharge. Monitoring emergency department visits and observation stays captures more post-discharge care utilization.

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Area of Science:

  • Nursing
  • Healthcare Management
  • Patient Outcomes

Background:

  • Unplanned acute care utilization post-discharge presents a significant challenge in healthcare systems.
  • Instrumental support plays a crucial role in successful patient recovery and transition from hospital to home.

Purpose of the Study:

  • To evaluate the relationship between registered nurse (RN) and patient perceptions of instrumental support and unplanned acute care utilization within 60 days of hospital discharge.
  • To determine if RN assessments of post-discharge support predict subsequent acute care needs.

Main Methods:

  • Retrospective analysis of 13,361 patient records from three hospitals in the southeastern United States.
  • Utilized the Readiness for Hospital Discharge Survey (RHDS) to assess patient and RN perceptions of instrumental support.
  • Employed logistic regression to analyze the association between RHDS scores and unplanned acute care utilization (ED visits, observation stays, readmissions).

Main Results:

  • Patients requiring hospital-based acute care within 60 days of discharge had significantly lower average RN-RHDS scores compared to those who did not.
  • This finding suggests a correlation between perceived instrumental support and the likelihood of readmission or other acute care needs.

Conclusions:

  • Incorporating nursing assessments of expected post-discharge instrumental support can help identify high-risk patients.
  • Monitoring a broader range of acute care utilization, including emergency department visits and observation stays, provides a more comprehensive understanding of post-discharge care needs.