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Models of Discharge Care in Magnet® Hospitals

Bobay, Kathleen PhD, RN, NEA-BC; Bahr, Sarah J. MSN, RN, ACNS-BC; Weiss, Marianne E. DNSc, RN; Hughes, Ronda PhD, RN, FAAN; Costa, Linda PhD, RN, NEA-BC, FAAN

JONA: The Journal of Nursing Administration: October 2015 - Volume 45 - Issue 10 - p 485–491
doi: 10.1097/NNA.0000000000000239

OBJECTIVE: The aim of this article is to describe how the discharge preparation process is operationalized in Magnet® hospitals.

BACKGROUND: Nationally, there are intensive efforts toward improving discharge transitions and reducing readmissions. Discharge preparation is a core hospital function, yet there are few reports of operational models.

METHODS: This was a descriptive, Web-based survey of 32 Magnet hospitals (64 units) participating in the Readiness Evaluation and Discharge Interventions study.

RESULTS: Most hospitals have adopted 1 or more national readmission reduction initiatives. Most unit models include several discharge preparation roles; RN case managers, and discharging RNs lead the process. Nearly one-half of units actively screen for readmission risk. More than three-fourths report daily discharge rounds, but less than one-third include the patient and family. More than two-thirds report a follow-up phone call, mostly to assess patient satisfaction.

CONCLUSIONS: Magnet hospitals operationalize discharge preparation differently. Recommended practices from national discharge initiatives are inconsistently used. RNs play a central role in discharge planning, coordination, and teaching.

Author Affiliations: Associate Professor (Drs Weiss, Bobay, and Hughes), PhD student (Ms Bahr), College of Nursing, Marquette University, Milwaukee, Wisconsin; Assistant Professor (Dr Costa), School of Nursing, University of Maryland, Baltimore.

The authors were commissioned by the American Nurses Credentialing Center (ANCC) to conduct this study.

The results, analysis, conclusions, and recommendations of the study, MU, authors, and/or researchers are independent of ANCC and do not necessarily reflect the views of ANCC.

The authors declare no conflicts of interest.

Correspondence: Dr Bobay, College of Nursing, Marquette University, PO Box 1881, Milwaukee, WI 53201 (

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