Helping Patients Living in Rural Areas Transition from Hospital to Home—The ROADMAP Study

Document Type


Publication Date


Publication Title

PCORI Patient-Centered Outcomes Research Institute



To evaluate the effectiveness of a hospital discharge planning program designed for patients living in rural areas on reducing readmissions and emergency department (ED) visits compared with usual discharge planning services

Study Design

Design ElementDescription Design Quasi-experimental study Population 127 adults ages 18–75 living in rural areas of Montana who had at least one overnight hospital stay Interventions/
  • ROADMAP program
  • Usual discharge planning services

Primary: number of hospital readmissions, number of ED visits, proportion of patients with at least 1 hospital admission or ED visit during the first 30 days following discharge

Secondary: number of primary care visits in the first 90 days after discharge, functional and mental health, patient-reported quality of discharge planning and services, patient perspectives on delivery of rural transition services Timeframe 30-day postdischarge follow-up for primary outcomes

This quasi-experimental time series study compared the effectiveness of the Rural Options At Discharge Model of Active Planning (ROADMAP) program with usual discharge planning services on reducing readmissions and ED visits.

Researchers created the ROADMAP program to support patients who live in rural areas after hospital discharge. Researchers enrolled patients receiving care at regional hospitals in four counties on a rolling basis. At the start of the study, hospitals in each county provided usual services. During the study period, the researchers introduced the ROADMAP program in one county at a time.

In the ROADMAP program, hospital staff conducted an assessment of patients’ postdischarge needs. Based on this assessment, hospital staff provided resources to support patients as they transitioned home, such as help with cleaning or grocery shopping. Staff also coordinated care between regional and local healthcare providers.

For patients receiving usual discharge planning services, hospital staff provided a treatment and medication summary and standard educational materials about postdischarge treatment and self-care. Staff also helped arrange patients’ transportation home.

The study included 127 patients living in rural areas of Montana. Of these, 87% were white, and 10% were American Indian or Alaska Native. The average age was 61, and 57% were male.

Patients completed a survey to assess study outcomes at enrollment and seven more times during the 90-day period after discharge. Researchers also looked at patients’ electronic health records to collect demographic information and assess risk factors for hospital readmission.

Patients, physicians, discharge planners, and hospital administrators helped design the study.


In the first 30 days after discharge, patients in the ROADMAP program reported fewer readmissions (p=0.05) compared with those receiving usual services. However, the two groups did not differ significantly in the proportion of patients with at least one readmission or ED visit or the number of ED visits reported. Patients in the ROADMAP program and those receiving usual services also did not differ significantly in any secondary outcomes.


The study only included patients ages 18 to 75. Results may differ for patients older than age 75. The study took place in one state and most patients in the study were white. Results may differ for people in other states or from other racial and ethnic backgrounds.

Conclusions and Relevance

Patients who participated in the ROADMAP program reported fewer total readmissions in the first 30 days after discharge. Other measures, including the total number of ED visits and the proportion of patients reporting any hospital readmissions and ED visits did not differ between patients in the program and those receiving usual services.

Future Research Needs

Future research could explore other ways to improve discharge services for patients living in rural areas.


Emergency Medicine