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Table 3 Overview of change determinants, theory-based methods, strategies and practical applications, and evidence

From: Improving patient discharge and reducing hospital readmissions by using Intervention Mapping

Determinants and change objectives Theory-based methods Examples of strategies/ practical applications Examples of activities and materials References* Evidence†
Individual healthcare provider
Aware of the consequences of suboptimal hospital discharge Knowledge transfer/Active learning Education in the medical and nursing curriculum Lectures on patient handover and exercises with workbook and online materials (e.g., communication skills and discharge letter requirements) 52 3a
Perceive handover administrative tasks as important part of patient discharge care and act accordingly Stimulus control/ Reinforcement Punishment by financial penalties; visual electronic reminders Red, orange and green flags indicating status of discharge letter and planning; visualization of deadline for sending discharge letter NF NA
Outward focus by hospital-based care providers to ensure continuity of care after discharge Integrated care Post-discharge monitoring of follow-up Standard post-discharge telephone call or home visit to the patient to evaluate follow-up, provide additional instructions and answer questions 53 1a
Hospital and primary care provider collaborative during the discharge process Integrated care/ Intergroup contact/ Case management Case conference Hospital or community-based face-to-face or telephone meetings between hospital and primary care providers 54-57 1b
Liaison person Designated care provider coordinating hospital discharge, follow-up care and the communication between hospital and primary care providers 58-60 1b
Knowledge and understanding of the primary care organization, expectations and needs Team building/ Intergroup contact/ Shifting perspective Meetings between hospital and primary care providers to increase mutual understanding and respect between both parties Focus group sessions, regular meetings and site visits to get to know each other, to learn each other’s organization and needs and to identify improvement opportunities 61 1b
Structural, problem-related feedback between hospital and primary care providers Stimulus control Means to facilitate and stimulate structural feedback Standard feedback form and return envelop along with discharge letter send to primary care providers NF NA
Patient-centered attitude Modeling/ Individualization Use of plain, patient-friendly, nonmedical language Discharge summary in language that is understandable for patients and relatives 62 1b
Active listening Teach back Care provider checks if patients received all discharge information needed and if they understood the received information 63 2b
Guidelines and standards of evidence-based practice Standardized working processes Standardized discharge letter (e.g. templates, formats) Templates, formats, required (web-based) fields, clinical decision-support, pick lists 64-66 1b
Standardized discharge planning Guidelines, protocols, checklists for discharge planning, organizing follow-up 67-68 1b
Medication reconciliation Standardised medication reconciliation checklist/medication discrepancy tool/ reconciliation by (liaison) pharmacist 54,57,65-67,69-71 1b
Shared electronic information exchange system Multi-disciplinarycollaboration Shared electronic patient information system Electronic notifications to primary care providers to inform them about patient hospital visits and to provide them (web-based) access to available discharge information 65,66,71-73 1b
Patient and relative
Participation in the discharge process Self- management/ Guided practice Encouraging and facilitating patients in self-management skills Provide patient with discharge record (e.g., active problem list, medication, allergies, patient concerns) owned and maintained by the patient to facilitate cross-site information transfer 62,74,75 1b
Skills and dare to speak up Coaching/ Guided practice Encouragement to assert a more active role during discharge Question form for patients 74 1b
Understanding of medical history and/or medication Guided practice/ Knowledge transfer Medication counseling at the hospital at discharge or at the patient’s home Visits by a pharmacist counselor 76 1b
  1. NF = not found; NA = not available.
  2. *The majority of the references relate to interventions or a component of a studied intervention program with an aim to improve hospital discharge. Other types of interventions (e.g., improving clinical handovers within the hospital) were also used as references in case they were considered to be relevant and appropriate for improving hospital discharge.
  3. †Grading of evidence, adapted and adjusted from the Oxford Centre for Evidence-based Medicine Levels of Evidence33: 1b = systematic review or meta-analysis of randomized controlled trials (RCTs); 1a = RCT of good-moderate quality or sufficient size and consistency; 3-4 = comparative trials (non-randomized, cohort studies, patient-control studies); 4 = non-comparative studies; 5 = Expert committee reports, opinions and/or clinical experience of respected authorities.