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Supplemental Digital Content
Sources for Table 2. Tools for Operationalizing Hospital Discharge Preparation
Tool REFERENCE
ESDP (Early Screen for Discharge
Planning)
Holland DE, Harris MR, Leibson CL, Pankratz VS, Krichbaum KE. Development and validation of a screen for specialized discharge planning services. Nurs Res. 2006;55(1):62-71.
BRASS ( Blaylock Risk Assessment
Screen)
D 2 S 2 ( Discharge Decision Support
System)
Blaylock A, Cason C. Discharge planning: predicting patients' needs. J Gerontol Nur 1s.992;18(7):5-10.
Bowles KH, Holmes JH, Ratcliffe SJ, Liberatore M, Nydick R, Naylor MD. Factors identified by experts to support decision making for post acute referral. Nurs Res. 2009 Mar-Apr;58(2):115-122.
BOOST 8Ps
Transitional Care Model, screening criteria
LACE
Society of Hospital Medicine. Project BOOST: Better Outcomes by Optimizing Safe Transitions. www.hospitalmedicine.org. Accessed 12-30-14.
Bixby MB, Naylor MD. The Transitional Care Model (TCM): Hospital discharge screening criteria for high risk older adults.
General Assessment Series: Best Practices for Older Adults. The Hartford Institute for Geriatric Nursing, New York
University, College of Nursing. 2009:26. http://consultgerirn.org/uploads/File/trythis/try_this_26.pdf. Accessed 12-30-
14.
Van Walraven C, Dhalla IA, Bell C,. et al. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. Can Med Assoc J. 2010;182(6):551-557.
Hospital Readmission Prediction
Model
Hasan O, Meltzer SA, Shaykevich CM, et al. Hospital readmission in general medicine patients: A prediction model. J Gen
Intern Med. 2010;25(3):211-219.
Risk Prediction Models for Hospital
Readmission: Systematic Review
Kansagara DH, Englander A, Salanitro D. et al. Risk prediction models for hospital readmission: A systematic review.
JAMA. 2011;306(15):1688-1698.
Care Coordination Measures Atlas McDonald KM, Schultz E, Albin L, et al. Care Coordination Atlas Version 4 (Prepared by Stanford University under subcontract to American Institutes for Research on Contract No. HHSA290-2010-00005I). AHRQ Publication No. 14-0037-
EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2014. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/ccm_atlas.pdf. Updated
June 2014. Accessed 12-30-14.
Schultz EM, Pineda N, Lonhart J, Davies SM, McDonald KM. A systematic review of the care coordination measurement landscape. BMC Health Serv Res. 2013;13:119 doi:10.1186/1472-6963-13-119

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National Voluntary Consensus
Standards for Care Coordination
(NQF)
Care Transitions Measure (CTM-
15, CTM-3)
Quality of Discharge Teaching
Scale
Parry C, Mahoney E, Chalmers S, Coleman EA. Assessing the Quality of Transitional Care: Further Applications of the Care
Transitions Measure. Med Care. 2008;46:317-322.
IDEAL Discharge Planning checklist Agency for Healthcare Research and Quality. Strategy 4: Care transitions from hospital to home: IDEAL discharge planning. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/index.html. Accessed 12-30-
14.
Rapid Evaluation of Adult Literacy in Medicine – Short Form (REALM)
Rapid estimate of adult literacy in medicine. http://www.ahrq.gov/professionals/quality-patientsafety/pharmhealthlit/realm-r.html. Accessed 12-30-14.
Weiss ME, Piacentine LB, Lokken L., et al. Perceived readiness for hospital discharge in adult medical-surgical patients.
Clin Nurse Spec:21:31-42.
PREPARED Instruments
Brief-PREPARED
Readiness for Hospital Discharge
Scale
National Quality Forum (NQF). Preferred practices and performance measures for measuring and reporting care coordination: A consensus report. Washington, DC: NQF; 2010. http://www.qualityforum.org/Publications/2010/10/Preferred_Practices_and_Performance_Measures_for_Measuring_a nd_Reporting_Care_Coordination.aspx. Accessed 12-30-14
Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for hospital discharge from the patient’s perspective: The Care Transitions Measure. Med Care. 2005;43:246-255.
University of South Australia, international Centre for Allied Health Evidence: Discharge Planning http://www.unisa.edu.au/Research/Sansom-Institute-for-Health-Research/Research-at-the-Sansom/Research-
Concentrations/Allied-Health-Evidence/Quality-Care/DCP/#PREPARED. Accessed 12-20-14.
Graumlich JF, Novotny NL, Aldag JC. Brief scale measuring patient preparedness for hospital discharge to home:
Psychometric properties. J Hosp Med. 2009;3(6):446-454.
Weiss ME, Piacentine LB. Psychometric properties of the Readiness for Hospital Discharge Scale. Journal of Nursing
Measurement, 2006;14(3):163-180.
PADQ-E (English version)
Post-Discharge Coping Difficulty
Scale
Holland DE, Mistiaen P, Knafl GJ, Bowles KH. The English translation and testing of the Problems After Discharge
Questionnaire. Soc Work Res. 2011;35(2):107-116.
Weiss, M.E., Piacentine, L.B., Lokken, L., Ancona, J., Archer, J., Gresser, S., et al. (2007). Perceived readiness for hospital discharge in adult medical-surgical patients. Clin Nurse Spec, 21, 31-42.

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