Background & Goal
More than a decade of funded research to Dr. Kathryn Bowles’ interdisciplinary team revealed both a lack of standards and great variation in the referral decision making process of hospital discharge planners for older patients from acute care to post-acute care (PAC). With over 13 million older adults dependent on referral decisions made by discharge planners each year, many older adults were discharged home to self-care with multiple unmet needs and risk factors for poor outcomes. The Bowles’ team demonstrated that patients who needed post-acute care but didn’t receive it were readmitted five times more often than similarly situated patients who did receive post-acute care. Armed with this troubling data, Dr. Bowles’ team obtained NIH funding from the National Institute of Nursing Research to build and test a solution.
The resulting nurse developed and designed Discharge Decision Support System (D2S2) is transforming the way clinicians identify high-risk patients and make referral decisions about who needs post-acute care.
Unlike most risk screening tools that rely on administrative data and medical diagnoses that lack acceptable sensitivity and specificity to accurately identify those at risk, the Discharge Decision Support System is an evidence-based six-item screening tool that uniquely focuses on the factors that influence the self-care ability of patients once they are discharged.