Site | TNP Intervention Core Components* Sustained | High Sustainability of Core Components | Moderate Sustainability of Core Components | Low Sustainability of Core Components | No Sustainability of Core Components | Reported Barriers at Site |
---|---|---|---|---|---|---|
Actions taken to implement TNP | Continue under original structure | Continue under alternative organizational structure | Parts of Service continue | Transfer of some or all services to other providers | Barriers that impacted sustainment of core components | |
Site 1 | • Assess veteran and family discharge readiness • Follow up appointment with Patient Aligned Care Team (PACT) |  | • Steps carried out by inpatient coordinators in Utilization Management Department |  |  | Leadership & Outcomes |
Site 2 | • Post-discharge phone call to Veteran • Post discharge communication with PACT |  | • Former Transitions Nurse continues to support TNP Veterans • 10 new care coordinators hired |  |  | Leadership & Outcomes |
Site 3 | • Assess Veteran and family discharge readiness • Follow-up appointment with PACT • Post discharge communication with PACT |  | • Steps carried out by two newly hired nurse transitions coordinators |  |  | Leadership, Outcomes, & Role Duplication |
Site 4 | •TNP hospitalist will still take TNP phone calls and offer rural discharge guidance |  |  | TNP hospitalist will still take TNP phone calls and offer rural discharge guidance |  | Leadership & Outcomes |
Site 5 | N/A |  |  |  | Services transferred back to ‘Discharge Expeditor’ role that was in place prior to TNP. | Leadership |
Site 6 | N/A | Â | Â | Â | Transfer of this role to discharge planners including resources and clinic contacts | Leadership, Outcomes, & Role Duplication |
Site 7 | N/A | Â | Â | Â | Services transferred back to process that was in place prior to TNP. | Outcomes |
Site 8 | N/A | Â | Â | Â | Services transferred back to process that was in place prior to TNP. | Outcomes |
Site 9 | N/A | Â | Â | Â | Transfer of this role to discharge planners including resources and clinic contacts | Leadership |
Site 10 | N/A | Â | Â | Â | Transfer of this role to discharge planners including resources and clinic contacts | Outcomes & Leadership |