Montana Rural Options at Discharge – Model of Active Planning

NOTE: Links to ROADMAP products for rural discharge planning are found below the project summary.

ROADMAP Project Overview

Logo of the Montana ROADMAP project whic reads "Rural Options Discharge Model of Active Planning" within the outline of the state of Montana. Logos of the University of Montana and St. Patrick Hospital are also included.

Hospital discharge challenges for rural patients

Residents of rural and frontier counties experience significant disparities in healthcare access and outcomes when compared to their urban counterparts. The organization of health care delivery contributes significantly to these disparities.

Rural residents can face many challenges when they have to go to a hospital in a distant city for treatment and then return home to recover. Their social support network is stretched in having to travel. Personal and family routines are disrupted, and they may not have anyone to provide assistance with daily responsibilities, such as on a farm or ranch. In addition, providers at a Regional Referral Hospital may not be familiar with the resources available in patient’s home community and might be unable to make effective referrals. The transition back home is also problematic because discharge planning generally does not adequately account for limited access to care in rural areas.

ROADMAP Project: Testing solutions for rural hospital discharge

The Montana ROADMAP project created and tested an enhanced discharge and rural transition supports program that facilitates patients’ transitions from in-patient hospitalization back home to a small town or rural community. Assuming that half of the discharges to rural communities benefit from this process, we estimate that comprehensive enhanced discharge planning and transition support could save as much as $2 billion annually.

Goals

The specific aims of this research project were:

  • To determine rural patients’ actual experience of the discharge planning process
  • To involve patients and rural providers in designing and evaluating a contextually appropriate rural transition model that improves patient outcomes (Montana ROADMAP)
  • To reduce re-hospitalizations, emergency department visits, and primary care visits

In addition to improving patient outcomes, this study generated new knowledge about the dynamic interaction between personal and environmental factors over time. Its findings are immediately useful for rural Centers for Independent Living, which are constantly intervening at the person and environment level to maximize community participation. This type of information could substantially contribute to accessibility advocacy efforts.  Similarly, these results may contribute to intervention and policy development that can maximize participation opportunities for rural people with disabilities.

ROADMAP Project Products

Introduction to the Project and Administration

Full Project Manual | Providing Patient-Centered Enhanced Discharge Planning and Rural Transition Support: Building a Rural Transitions Network between Regional Referral and Critical Access Hospitals

  • Seekins, T., Boehm, H., Wong, J. L., Yearous, L., and Smith, A., (2017).  Providing patient-centered enhanced discharge planning and rural transition support: Building a rural transitions network between regional referral and critical access hospitals. Missoula, MT: Rural Institute on Community Inclusion, University of Montana.

Tablet Application

  • Technical report: Greene, S., Szalda-Petree, A., Seekins, T., Wong, J., and Eisenreich, B. (2017).  Providing patient-centered enhanced discharge planning and rural transition support: Programing a Rural Transition Needs Assessment. Missoula, MT: Rural Institute on Community Inclusion, University of Montana.
  • Training manual: Greene, S., Szalda-Petree, A., Seekins, T., Wong, J., and Eisenreich, B. (2017).  An application for a Rural Transition Needs Assessment: A training manual for hospital staff, Missoula, MT: Rural Institute on Community Inclusion, University of Montana.

Systematic Approach to Developing A Community Resource Bank

  • Seekins, T., Boehm, H., Greene, S., Long, R., Wong, J., & Eisenreich, B. (2017). A Systematic Approach to Developing a Local Health and Human Services Resource Bank for Rural Communities. Missoula, MT: Rural Institute on Community Inclusion, University of Montana.

Brief Description: Discharge Orders Verification Checklist

  • Seekins, T., Sliter, L., Smith, A, Wong, J., Eisenreich, B., Greene, S., & Long, R. (2017).  Verifying Discharge Order Checklist. Missoula, MT: Rural Institute on Community Inclusion, University of Montana.

Long Term Goal Assessment Report

  • Seekins, T., Boehm, H., Greene, S., Long, R., Wong, J., Eisenreich, B., Yearous, L., & Smith, A, (2017). A Systematic Approach to Developing a Local Health and Human Services Resource Bank for Rural Communities. Missoula, MT: Rural Institute on Community Inclusion, University of Montana.

Product related to Administration of a Transition Group

  • Management Manual: Seekins, T., Yearous, L., Smith, A., Boehm, H., and Wong, J. L. (2107). Managing a Team of Hospital Transition Coordinators and Local Community Transition Coordinators. Missoula, MT: Rural Institute on Community Inclusion, University of Montana.

Products related to Patient Experience

Case Summaries of Intervention Patients

  • Nominated case summaries: Seekins, T., Wong, J. L., Yearous, L., Smith, A., Long, R. & Greene, S. (2017). Enhanced discharge planning and rural transitions supports: Selected case summaries from an experimental evaluation, Missoula, MT: Rural Institute on Community Inclusion, University of Montana.
  • Full set of case summaries: Seekins, T., Wong, J. L., Yearous, L., Smith, A., Long, R. & Greene, S. (2017). Montana ROADMAP: Fifty Case Summaries from an Experimental Evaluation, Missoula, MT: Rural Institute on Community Inclusion, University of Montana.

Rural Transition Process

  • Seekins, T., Boehm, H., Wong, J. L., Yearous, L. (2017). Montana ROADMAP: Creation and Evaluation of the RTM14, Missoula, MT: Rural Institute on Community Inclusion, University of Montana.

Rural Transition Needs Assessment and LACE+

  • Seekins, T., Yearous, L., Wong, J. L., Long, R., & Smith, A. (2017). Montana ROADMAP: A comparison of patient needs and their risk score, Missoula, MT: Rural Institute on Community Inclusion, University of Montana.

Acknowledgements

Years of RTC:Rural research, development, and stakeholder engagement has influenced this rural-focused project, with leadership from long time RTC:Rural Director and rural expert, Dr. Tom Seekins.

Funding

Research leading to the preparation of this manual was supported, in part, by an award (AD 12-11-4788) from the Patient-Centered Outcomes Research Institute (PCORI). The views presented in this manual are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute, its Board of Governors or Methodology Committee.

Principle Project Staff

  • University of Montana: Tom Seekins, Jennifer Wong, Casey Ruggierro, Craig Ravesloot, Patricia O’Brien, Susan Greene, Ryan Long, Jon Graham, Benjamin Eisenreich, Allen Szalda-Petree
  • Saint Patrick Hospital: Heidi Boehm, Tim Descamps, Joe Knapp, Linda Yearous, AnnaJean Smith, Becky Brooks, Noah Becker, Chandala Curtiss, Sandy Beaudette
  • Critical Access Hospitals: Ali Church, Shelby Zenahik, Greg Hanson, Leisha Armstrong, Maria Koslosky, Gail Eide, Shiloh McCready, Katie Bateman, Marie Hamilton, Benjamin Murray
  • Subject Matter Experts: Myrna Seno, Linda Torma, David Claudio, Carol Bishoff
  • Patient Design Team: Lynne VanZonnenfeldt, Lou Alcott, Mike Bedick, Vickie Radford

Previous Work

In Care Transitions, a Chance to Make or Break Patients’ Recovery

Project Dates

May 2013-Oct 2017