1. Wallace, Andrea PhD, RN
  2. Papke, Todd PhD
  3. Davisson, Erica MSN, RN
  4. Spooner, Kara MSN
  5. Gassman, Laura MHA, BSN, RNC-EFM


Purpose of Study: Despite over three decades of research linking social support and optimal health outcomes, social support is not systematically assessed or addressed during clinical care. This study sought input from health care providers to inform the design of an intervention intended to facilitate assessment of social support in a way that could aid in anticipatory planning during the process of hospital discharge.


Primary Practice Setting(s): Using a purposive sampling strategy, data were collected from providers in two acute care settings serving rural patients, one academic and one community based. Opinions about what an assessment of social support would seek to accomplish, what is currently done and by whom, and the preferred format for delivery were elicited during a series of individual and group interviews. During phase two, feasibility was assessed with three inpatient nurses over 3 clinical days. Field notes were analyzed throughout the project using rapid data analysis techniques.


Results: Health care providers endorsed the creation of an assessment and stated that target users would include all members of the discharge team (e.g., clinical nurses, case managers, discharge coordinators, hospitalists, and specialty care). They identified the need for a patient-family resource (vs. a traditional provider-facing assessment). Participants stated that, although both the information collected and the interview process would meet a need to increase patient engagement in inpatient settings, competing clinical demands would require a tool that was easily completed by patients and family and seen as directly informing clinical activities. To this end, although focusing on the eventual development of an electronic tool seemed valuable, a hard-copy resource was considered more feasible for patient use at the present time. The preliminary test of the resulting hard-copy "Going Home Toolkit" demonstrated potential feasibility and usefulness during clinical practice.


Implications for Case Management Practice: There is need for not only assessing patients' supportive networks during discharge planning, but to do so in a way that would facilitate directed communication between, and engagement with, team members, patients, and families. Especially in light of new legislation focusing on involvement of caregivers, a tool such as the "Going Home Toolkit" may facilitate important conversations about, and planning around, patients' supportive resources at home.