RUG-ADL Assessment | The Resource Utilization Group – Activities of Daily Living Assessment measures functional status at discharge, readmission and at 30-day follow-up. This four-item validated questionnaire assesses a patient’s independence with mobility, toileting, transfer and eating [39]. |
Pain | The National Institutes of Health Numeric Rating Pain Scale assesses pain intensity at the time of discharge, readmission and 30-day follow-up [40]. |
Pain Meds | Total dose of pain medication administered 24Â h (7Â am-7Â am) before discharge |
Perceived Stress Scale | Cohen’s Perceived Stress Scale (PSS) is a 10-item scale that quantifies patient’s stress. The PSS has been shown to correlate with health behavior and health services utilization [41]. |
CES-D4 | The Center for Epidemiologic Studies Depression Screen, 4-item version, assesses psychological distress at the time of discharge. The CES-D4 has been shown to be have a positive predictive value of 85% for depression in an older adult population [31]. |
MoCA | The Montreal Cognitive Assessment is a validated tool to assess a patient’s cognitive function. This tool has a positive predictive value of 89% for mild cognitive impairment (90% sensitivity; 87% specificity) when compared to clinical criteria supported by psychometric measures [42]. |
Caregiver Accessibility | These questions were guided by the literature around the immediacy and availability of the designated caregiver (i.e., does caregiver live with patient) [43, 44]. |
Transportation | Patient access to transportation and burden of transportation (number of post-operative visits and travel distance). |
CTM-15, adapted | The Care Transition Measure is a 15-item scale that addresses the hospital’s efforts at care coordination at discharge. The survey also assesses patient self-efficacy in implementing the discharge plan. The tool was designed as a post-discharge, recall assessment [45]. We will adapt the tool: a) to assess these items on the day of discharge; b) to assess patient self-efficacy with wound, indwelling device, new ostomy or durable medical equipment, as applicable; and c) to assess patient understanding of whom and when to contact regarding warning signs or symptoms that may arise. |
Institute for Healthcare Improvement Readmission Tool | This tool was developed by IHI as part of a conceptual roadmap to reduce avoidable re-hospitalizations by intervening at the system level. The tool will be adapted for surveying patients at readmission [46]. |
Brief Survey of Post-operative Care | Queries patient on unplanned emergency visit or readmission at an outside hospital; keeping post-operative appointments; difficulty getting medications filled (costs) and refilled (especially pain medication); receipt of home health or durable medical equipment. |