The objective of this multidisciplinary research project is to improve discharge planning for hospitalized patients. We will evaluate an intervention that allows targeting of a case management discharge planning intervention using a prediction rule to identify patients at increased risk of using medical services after discharge. The screening instrument will utilize clinical and health status data collected from patients at the time of admission as a part of routine care. In the case management intervention, nurse case managers will function as members of medical teams and work to effect appropriate and efficient discharge arrangements. In this prospective trial, patients cared for by medical teams employing the targeted case management approach will be compared to patients cared for by standard care medical teams. In addition to diagnosis-adjusted length of hospital stay and total cost outcomes determined at the time of discharge, we will also evaluate patient satisfaction, patient health status, and post-hospitalization resource utilization at one month after discharge. The hypothesis of the study is that this targeted case management intervention will improve the efficiency of hospital discharge planning services. The results of this study will have significant implications for the implementation of hospital discharge planning strategies.
