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 |
Interpersonal | |||||
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 | |
Organizational | |||||
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 | ||
Technical | |||||
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 |