Table 2.

RE-AIM measures in the rural transition nurse program

RE-AIM measures	TNP definition	Measurement
R—Reach	▪ Proportion of eligible rural Veterans enrolled at each site	▪ Number of Veterans enrolled each month ▪ Proportion of eligible Vets enrolled
E—Effectiveness	▪ Primary outcome is emergency department visits and hospitalizations in the 30 days following index discharge; Cost of utilization (ED/hospital); Satisfaction of Veterans and providers	▪ Hospital readmission rates ▪ Return on Investment ▪ Provider satisfaction surveys ▪ Qualitative semi-structured interviews ▪ Veteran satisfaction surveys
A—Adoption	▪ Proportion of inpatient providers that refer eligible Veterans to the TN for enrollment in the TNP ▪ Proportion of PACT providers that complete communication (close communication loop through Lync, email, phone) for care coordination with the TN as part of the TNP	▪ Number of Veterans enrolled each month ▪ Proportion of eligible Vets enrolled, 6 months after enrollment begins, and 1 year after enrollment begins
I—Implementation	▪ Evaluating what components of the manual and toolkit have been implemented and how they have been adapted (using Stirman framework)	▪ Regular phone calls with TNs will identify adaptations, barriers, and facilitators to implementation ▪ Survey to measure TN and Hospital Champion view of program ▪ Observational assessment of TN competency and adherence to TNP core components, as well and pre and post-test ▪ Semi-structured interviews with TNs, Hospital Champions, inpatient and PACT clinicians, and Veterans to identify internal and external factors that affect TNP implementation, as well as barriers and facilitators to implementation ▪ Measurement of adaptations using real-time tracking with and adapted Stirman framework
M—Maintenance	▪ Funding or expansion of TN role at expansion sites after 3 years of funding	▪ Return on investment ▪ Continued use and improvement of TNP program