Skip to main content

Table 1 Reported Plans for TNP Sustainment after Funding Period Ended for Each Site

From: Sustainment stories: a qualitative analysis of barriers to sustainment of the National Rural Transitions of Care Nurse Program

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

   

Transfer of this role to discharge planners including resources and clinic contacts

Leadership, Outcomes, & Role Duplication

Site 7

N/A

   

Services transferred back to process that was in place prior to TNP.

Outcomes

Site 8

N/A

   

Services transferred back to process that was in place prior to TNP.

Outcomes

Site 9

N/A

   

Transfer of this role to discharge planners including resources and clinic contacts

Leadership

Site 10

N/A

   

Transfer of this role to discharge planners including resources and clinic contacts

Outcomes & Leadership

  1. *The core components of the intervention are 1) TN sets up follow up appointment at PACT site 2) TN assesses patient discharge readiness 3) Follow up post-discharge call to patient 4) engage the primary care provider and PACT provider in electronic communication
  2. *Table based on Lapelle’s sustainment work [15]