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A Model for Hospital Discharge Preparation: From Case Management to Care Transition

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

JONA: The Journal of Nursing Administration: December 2015 - Volume 45 - Issue 12 - p 606–614
doi: 10.1097/NNA.0000000000000273

There has been a proliferation of initiatives to improve discharge processes and outcomes for the transition from hospital to home and community-based care. Operationalization of these processes has varied widely as hospitals have customized discharge care into innovative roles and functions. This article presents a model for conceptualizing the components of hospital discharge preparation to ensure attention to the full range of processes needed for a comprehensive strategy for hospital discharge.

Author Affiliations: Professor (Dr Weiss), Associate Professor (Drs Bobay and Hughes) and PhD Student (Ms Bahr), College of Nursing, Marquette University, Milwaukee, Wisconsin; Assistant Professor (Dr Costa), School of Nursing, University of Maryland, Baltimore; and Clinical Nurse Researcher, Department of Nursing, and Associate Professor of Nursing, College of Medicine (Dr Holland), Mayo Clinic, Rochester, Minnesota.

The authors declare no conflicts of interest.

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

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