Table 2 RE-AIM measures in the rural transition nurse program

R—Reach

▪ Proportion of eligible rural Veterans enrolled at each site

▪ Number of Veterans enrolled each month

▪ Proportion of eligible Vets enrolled

E—Effectiveness

▪ Primary outcome is emergency department visits and hospitalizations in the 30 days following index discharge; Cost of utilization (ED/hospital); Satisfaction of Veterans and providers

▪ Hospital readmission rates

▪ Return on Investment

▪ Provider satisfaction surveys

▪ Qualitative semi-structured interviews

▪ Veteran satisfaction surveys

A—Adoption

▪ Proportion of inpatient providers that refer eligible Veterans to the TN for enrollment in the TNP

▪ Proportion of PACT providers that complete communication (close communication loop through Lync, email, phone) for care coordination with the TN as part of the TNP

▪ Number of Veterans enrolled each month

▪ Proportion of eligible Vets enrolled, 6 months after enrollment begins, and 1 year after enrollment begins

I—Implementation

▪ Evaluating what components of the manual and toolkit have been implemented and how they have been adapted (using Stirman framework)

▪ Regular phone calls with TNs will identify adaptations, barriers, and facilitators to implementation

▪ Survey to measure TN and Hospital Champion view of program

▪ Observational assessment of TN competency and adherence to TNP core components, as well and pre and post-test

▪ Semi-structured interviews with TNs, Hospital Champions, inpatient and PACT clinicians, and Veterans to identify internal and external factors that affect TNP implementation, as well as barriers and facilitators to implementation

▪ Measurement of adaptations using real-time tracking with and adapted Stirman framework

M—Maintenance

▪ Funding or expansion of TN role at expansion sites after 3 years of funding

▪ Return on investment

▪ Continued use and improvement of TNP program