The purpose of this study is to improve the experience of discharge of adult medical surgical patients through improved discharge preparation communication between patients and care team members, with subsequent improvement in the post-discharge experience. Obtaining multiple perspectives on discharge readiness creates the opportunity for patient and care team to partner in identifying deficiencies in discharge readiness that warrant anticipatory, compensatory, or corrective interventions prior to discharge, with the goal of averting post-discharge problems and utilization. The results will also inform development and translation of tools for assessment of discharge readiness to clinical care environments.

Specific Aims are to:

1. Describe patterns of communication about discharge and collaboration among members of the health care team
2. Conduct psychometric testing of 3 forms of the Readiness for Hospital Discharge Scale (RHDS - MD, RN, Patient)
3. Describe relationships between care team communication, patient perceptions of quality of discharge preparation and perceived readiness for discharge, care team (RN and MD) assessments of discharge readiness, and post-discharge outcome ( post-discharge coping difficulty, Emergency Department (ED) use, and 30 day readmission.
4. Determine the impact of an intervention with the inpatient care team to improve discharge preparation communication.

H1: Patient perceptions of discharge readiness, post-discharge coping difficulty, ED use and readmission will improve following a care team educational intervention about discharge preparation, compared to pre-intervention baseline measures.

H2: Care team members will report improved frequency and amount of discharge preparation communication following a care team educational intervention about discharge preparation, compared to pre-intervention baseline measures.

H3: RN-MD collaboration will increase following a care team educational intervention about discharge preparation, compared to pre-intervention baseline measures

Inclusion Criteria:

• inpatient care team members from 2 nursing units of an academic medical center: Attending physician, resident, medical students, mid-level providers, staff RNs, and case managers/discharge coordinators
• adult medical-surgical patients admitted the 2 nursing units who are at least 18 years of age, speak English, and discharged directly home

Exclusion Criteria:

• patient discharged home with hospice care
• patients not discharged directly home
• decisionally incapacitated patients