1. ADRC/CLP National Meeting Wednesday, 2/24/2010 Person-Centered Hospital Discharge and Care Transitions This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency

2. Idaho Hospitals Of the 42 hospitals throughout Idaho, 24 are small, rural hospitals with 25 or fewer beds and a Critical Access Hospital designation. Of the remaining hospitals, 7 have between 26 and 99 beds. The other 11 have 100 or more beds. Out of necessity, personnel resources targeting person-centered planning (PCP) discharge are limited in these smaller hospitals, potentially impacting discharge planning from the outset. Community resources and referral services are often limited due to provider shortages throughout Idaho. 2

3. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 3 Project Goals Goal 1: develop a sustainable PCHDP model for rural and underserved areas. Goal 2: enhance systems of information exchange statewide.

4. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 4 Project Products Literature review of discharge planning research Website of searchable services & supports Best practices model for rural hospitals Webinar training on discharge related topics for providers Pre/post comparison research with 200 patients experiencing discharge

5. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 5 Case Managers Survey Methods and Results

6. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 6 Population of Discharge Planners List –provided by Idaho Hospital Association –Total with email addresses = 93 From administrators –20 Hospital administrators –20 Directors of nursing Responses –53 started the survey –47 (89%) complete surveys

7. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 7 Survey Tool –Survey Monkey Three surveys –2 questions survey (# of discharge planners and contact info) Hospital administrators Directors of Nursing –Full survey Discharge planners

8. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 8 Education Level 1.9% 19.2% 53.8% 25.0%

9. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 9 Expertise or Training

10. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 10 Required to complete training 34.6% 65.4%

11. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 11 Training in the last year 90.4% 9.6%

12. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 12 Hours of training, last year Average= 24 hours

13. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 13 Number of courses/events Average = 8.5 courses

14. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 14 Barriers

15. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 15 Topics covered 20.9 % 48.8 % 14.0 % 55.8 % 37.2 % 44.2 % 53.5 %

16. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 16 Topics covered Other –Pain Management –Certification: Diabetic Educator –Resources in the community –Bereavement Training –Grant writing –Management: Psychiatric medications –Access to medications for homeless people

17. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 17 Mode of training 90.7 % 44.2 % 37.2 % 30.2 %

18. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 18 How helpful was training 21.4 % 61.9 % 16.7 %

19. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 19 Future training

20. This publication has been created or produced by Idaho State University - Institute of Rural Health with financial assistance, in whole or in part, through a grant from the Centers for Medicare & Medicaid Services, the Federal Medicare agency 20 Preferred Format PreferredLeast Preferred

21. Russell Spearman: spearuss@isu.edu Debra Larsen: larsdeb2@isu.eduspearuss@isu.edularsdeb2@isu.edu