Date of Paper/Work


Type of Paper/Work

Systems Change Project

Degree Name

Doctor of Nursing Practice



First Advisor

Judith A. Johnson


This study was a quasi-experimental pilot study designed to determine the effectiveness of an interdisciplinary team to develop improved discharge teaching and process with inclusion of early provision of discharge goals, identification of barriers, and subsequent teaching and problem-solving of the barriers to impact patient perceived readiness for discharge. Discharge goals and barriers were identified early in the hospital stay for the intervention group and the control group received usual discharge planning. A questionnaire was given to the intervention group on admission to determine patient perceived goals and barriers. Based on the goals and barriers identified by the intervention group, the interdisciplinary team formulated an intensive discharge plan to meet patients’ goals and overcome barriers identified on admission. The investigator provided written goals at the bedside, planning brochure with video, and an anticipated discharge date was posted. A Perceived Readiness for Discharge Scale was administered prior to discharge to both groups, and two follow-up questionnaires post discharge were administered through follow-up phone calls. The phone calls and follow-up questionnaires were administered by an advanced practice nurse at 48-72 hours post discharge and at 10-14 days post discharge to assess any adverse events, patient satisfaction with the discharge process, and preparedness for discharge. This study contributed to knowledge present in the current literature which describes discharge planning and went further to investigate if an intensive discharge planning intervention through identification of goals and barriers early in the hospital stay improves perceived readiness for discharge. This study also looked at whether perceived readiness also influences patient satisfaction with the discharge process from hospital to home and if the concept of early identification of barriers and an intensive discharge process is associated with decreased adverse events and readmissions within 72 hours and 14 days post discharge.