Table 1.
Reported Plans for TNP Sustainment after Funding Period Ended for Each Site
| Site | TNP Intervention Core Components* Sustained | High Sustainability of Core Components | Moderate Sustainability of Core Components | Low Sustainability of Core Components | No Sustainability of Core Components | Reported Barriers at Site |
|---|---|---|---|---|---|---|
| Actions taken to implement TNP | Continue under original structure | Continue under alternative organizational structure | Parts of Service continue | Transfer of some or all services to other providers | Barriers that impacted sustainment of core components | |
| Site 1 |
• Assess veteran and family discharge readiness • Follow up appointment with Patient Aligned Care Team (PACT) |
• Steps carried out by inpatient coordinators in Utilization Management Department | Leadership & Outcomes | |||
| Site 2 |
• Post-discharge phone call to Veteran • Post discharge communication with PACT |
• Former Transitions Nurse continues to support TNP Veterans • 10 new care coordinators hired |
Leadership & Outcomes | |||
| Site 3 |
• Assess Veteran and family discharge readiness • Follow-up appointment with PACT • Post discharge communication with PACT |
• Steps carried out by two newly hired nurse transitions coordinators | Leadership, Outcomes, & Role Duplication | |||
| Site 4 | •TNP hospitalist will still take TNP phone calls and offer rural discharge guidance | TNP hospitalist will still take TNP phone calls and offer rural discharge guidance | Leadership & Outcomes | |||
| Site 5 | N/A | Services transferred back to ‘Discharge Expeditor’ role that was in place prior to TNP. | Leadership | |||
| Site 6 | N/A | Transfer of this role to discharge planners including resources and clinic contacts | Leadership, Outcomes, & Role Duplication | |||
| Site 7 | N/A | Services transferred back to process that was in place prior to TNP. | Outcomes | |||
| Site 8 | N/A | Services transferred back to process that was in place prior to TNP. | Outcomes | |||
| Site 9 | N/A | Transfer of this role to discharge planners including resources and clinic contacts | Leadership | |||
| Site 10 | N/A | Transfer of this role to discharge planners including resources and clinic contacts | Outcomes & Leadership |
*The core components of the intervention are 1) TN sets up follow up appointment at PACT site 2) TN assesses patient discharge readiness 3) Follow up post-discharge call to patient 4) engage the primary care provider and PACT provider in electronic communication
*Table based on Lapelle’s sustainment work [15]