Quality of Transition From Hospital to Home: The Influence of Nurse- and Patient-Reported Readiness

Identifying those at risk of poor outcomes after hospital discharge is a central focus of health care systems. Our purpose was to better understand whether and how patient- and nurse-assessed readiness for discharge (Pt- and RN-RHDS) is related to patient experiences after discharge. We conducted a prospective survey of 70 Veterans and their assigned nurses on the day of, and again with Veterans 2 weeks after, hospital discharge. The predictive model for post-discharge coping difficulty included educational level (p = .05) and an interaction between Pt-RHDS ratings and Pt-RN RHDS discordance (p = .01). The predictive model for patient-reported quality of hospital to home transition experience included Pt-RN RHDS discordance and an interaction between Pt-RHDS and the number of people living with the patient (p = .05). Our findings demonstrate that agreement between Pt- and RN-RHDS may be an important measure in work aiming to improve patient outcomes post-hospitalization.