Document Type

Practice Guidelines


University of Montana Rural Institute

Publication Date



Community Health and Preventive Medicine | Public Health


Residents of rural and frontier counties experience significant disparities in healthcare access and outcomes when compared to their urban counterparts. The organization of health care delivery contributes significantly to these disparities. Simply put, rural residents can face many challenges when they have to go to a hospital in a distant city for treatment and then return home to recover. The transition back home is also problematic because discharge planning generally does not adequately account for limited access to care in rural areas. The specific aim of this research project was to ascertain rural patients’ actual experience of the discharge planning process, and to involve patients and rural providers in designing and testing a contextually appropriate rural model that improves patient outcomes and reduces re-hospitalizations.

This manual was used in a research project, Rural Options at Discharge – Model of Active Planning (ROADMAP). Our objective was to develop and evaluate a model that improved the likelihood of a positive recovery and reduced the likelihood of re-hospitalization. Current trends in health care delivery suggest that the right supports provided to patients at the right time may improve outcomes and reduce re-hospitalizations. For patients being discharged from a tertiary care facility back to a small town or rural community, this support includes assistance in addressing instrumental and social support needs. The methods included in this manual come from the literature, from cutting-edge practices in the field of care coordination, from recommendations of medical care providers, from patients themselves, and from lessons learned through this research process.


rural health, rural hospital, healthcare, PCORI, self-management, discharge planning, Critical Access Hospital


© 2017 RTC:Rural

Granting Agency

Patient-Centered Outcomes Research Institute (PCORI)


Research leading to the preparation of this manual was supported, in part, by an award (AD 12-11-4788) from the Patient-Centered Outcomes Research Institute (PCORI). The views presented in this manual are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute, its Board of Governors or Methodology Committee.

Project Number

AD 12-11-4788