and 6: Implementation and Evaluation

A robust implementation process is vital to ensure program success. We made suggestions for developing an implementation plan for accomplishing program adoption and suggestions to create a plan for evaluating the effects and feasibility of the intervention program. The suggestions were based on literature regarding effective implementation strategies17,30'34'36, existing implementation toolboxes37'38, and a literature review on methods to evaluate complex interventions in health care35'39'40.

RESULTS

Step 1: Problem analysis

The health problem and the underlying causes are presented in figure 2. Published studies show that one in five patients experience an adverse event following hospital discharge, of which one in three is considered preventable41. Three percent of the adverse events lead to permanent disability, including death.

Figure 2. Model of suboptimal hospital discharge: overview of the health problem, causes and their determinants Determinants for health care professional behavior Health care professional behavioral causes INDIVIDUAL HEALTHCARE PROVIDER DETERMINANTS Poor information exchange between hospital and

Lack of awareness of consequences of suboptimal primary care providers:

hospital discharge delayed, incomplete, unclear or inadequate - Priority on providing medical or nursing care prevails information (e.g., discharge letters or

over administrative handover tasks medication lists)

- Lack of willingness, knowledge and skills to reflect, un- or misinformed health professionals (e.g., learn and improve discharge practice patient-specific needs)

- Relying too much on discharge routines

Poor coordination of care:

ENVIRONMENTAL DETERMINANTS hospital and primary care providers work as

Interpersonal separate actors

- Inward attitude delayed or poor discharge - Lack of collaborative attitude planning/organization of follow-up - Distant and negative attitudes/relationship between --- ► lack of preparing patients for discharge

hospital and primary care providers

- Lack of knowledge and understanding with Many discharge problems remain unspoken and organization, expectations and needs of primary care possible opportunities for improvement missed providers

- Lack of shared communication language Inadequate information exchange between - Lack of structural, problem-related feedback between healthcare professional and patiënt:

hospital and primary care providers formal and swift discharge consultations; - Lack patient-centered attitude lack of discharge information and -instructions

Organizational factors to patiënt (and relative) or given just before - Hospital size and identity actual discharge;

- Lack of priority and awareness on a managerial level use of medical-technical language by - Lack of guidelines, standards of evidence-based healthcare providers

practice overload of non-prioritized written and verbal - Work load/tim e pressure information received by patients at discharge

Determinants of patiënt behavior Patiënt behavioral causes

Patiënt and relatives are unaware of option to take a Patiënt does not ask for more specific (pro)active role to contribute to effective handover information

Patients are less skilled or don't dare to speak up Patiënt does not protest against discharge Patients do not know what to ask decisions

Neither patiënt nor family knows the medical W Lack of knowledge of patients

history/medication Patiënt forgets to handover discharge letter to Low health literacy/care givers use too difficult GP

language Patiënt does not signal specific needs Lack of family support

Developing a tailored hospital discharge intervention program 129

The one month unplanned readmission rates varied between 13%42 and 20%43. In around 15% of cases of readmission, this was due to failure in handover and thus preventable. Unnecessary hospital readmissions lead to a considerable suffering and extra costs. Hospital cost for preventable readmissions during 6 months was estimated at about $730 million7, and $44 billion per year for rehospitalizations within 30 days of hospital discharge44.

We found that ineffective handovers that led to patiënt readmissions are caused by poor information exchange, poor coordination of care and poor communication between hospital and primary care providers, and between care providers and patients. The underlying causes include attitudinal and behavioral factors (e.g., lack of understanding of the needs of the counterpart, a distant relationship and a lack of collaborative attitude between hospital and primary care providers), organizational factors (e.g., lack of guidelines), technical factors (lack of a shared electronic information system) or patiënt factors (e.g., patients are less skilled or don't dare to speak up)1012. All identified causes and their underlying factors are summarized in figure 2. Step 2: Matrices of change objectives

Intervention outcomes

Two outcome measures were selected in step 1 as measurable and feasible endpoints for an evaluation study: hospital readmission rates and adverse events rates after the hospital discharge.

Performance objectives

All performance objectives are listed in table 3. The performance objectives of the healthcare providers related to exchanging high-quality discharge inform ation to primary care providers and patients. For example, discharge letters that are complete (i.e., no redundant/irrelevant or missed information), accurate and understandable (i.e., structured presentation of information, explanation of abbreviations jargon), and patients being informed at discharge in plain language. Regarding coordination o f care, healthcare providers were expected to have organized and accurate follow-up services at patient's discharge in a timely manner and tailored to the patient's preferences and psychosocial needs (e.g., assessment of home setting, social risks and support). Examples of performance objectives for discharge com m unication are hospital care providers being accessible for primary care providers or patients and exchanging discharge information in time to support primary care providers or patients.

Patients are, if capable, expected to contribute to the continuity of care by participating in the discharge process (e.g., by handing over a discharge letter to their GP after being discharged), and by being w ell aw are about their health status (e.g., medical and medication history) and treatm ent plan.

Developing a tailored hospital discharge intervention program 131 Table 3. Performance objectives for healthcare providers and patients

Healthcare providers

Discharge information la . Complete discharge information lb . Clear discharge information lc . Accurate discharge information

Coordination of care 2a. Ensure that follow-up services are being organized at actual discharge 2b. Tailor follow-up care to patiënt needs and preferences

2c. Organize timely and accurate follow-up

Discharge communication 3a. Seek direct/personal contact with primary care counterpart

3b. Discharge information easily accessible to counterpart care providers and patients (and relatives)

3c. Exchange discharge information on time to primary care counterparts 3d. Inform patiënt (and relatives) personally and in timely manner

Patients

Participation in discharge process 4. Contribute, if capable, to the continuity of care in the discharge process Awareness of health status and

treatment

5. Well aware about medical history and medication use, diagnosis/indication and (side) effects of the treatment

Selected determinants and change objectives

The most important determinants (as perceived by experts in the field of patiënt handovers and described in step 2 of the methods) were classified according to the individual professional, interpersonal, organizational, technical and patiënt levels. Com biningthe performance objectives with the selected determinants resulted in two matrices with change objectives for healthcare providers and patients, which were the specific targets for the intervention. The matrices are presented in table 4.

Table 4. Matrices of change objectives

CARE PROVIDER BEHAVIOR,