Document Type

Practice Guidelines


University of Montana Rural Institute

Publication Date



Community Health and Preventive Medicine | Public Health


Researchers have suggested that readmissions following hospital discharge might be reduced by providing additional resources to patients most likely to be re-hospitalized. They have suggested three broad approaches to assessing the likelihood of readmission and prioritizing patients for extra support. These approaches include: (1) medical risk, (2) personal capacity, and (3) environmental. While work on assessing medical risk and personal capacity has been reported, few researchers have explored the role of environmental factors.

We used the third approach, an environmental perspective, to develop and test a Rural Transition Needs Assessment. This process involved patients in assessing their practical needs for recovery at home. Needs included several community factors that may affect a patient’s ability to achieve a smooth transition home. The environmental approach assesses a patient’s needs for community supports. A needs model may be somewhat less efficient than the other approaches because each individual’s needs must be assessed but it points neatly to solutions in the community. Further, it is less likely to provide services to those who do not need them or to miss providing service to those who do. Such an approach may complement and enhance standard risk and capacity assessments.


health and wellness, rural


© 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