Applying i-PARIHS to Identify Emerging Innovations in Hospital Discharge Decision Making in Response to System Stress: A Qualitative Study

Background The purpose of this qualitative study was to use a Learning Health System approach to identify factors influencing the emergence of innovation in rehabilitation hospital discharge decision-making during the Coronavirus 2019 (COVID-19) pandemic. Methods Rehabilitation clinicians were recruited from the Veterans Affairs Health Care System and participated in individual semi-structured interviews guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. Data were analyzed using a rapid qualitative, deductive team-based approach informed by directed content analysis. Results Twenty-three rehabilitation clinicians representing physical (N = 11) and occupational therapy (N = 12) participated in the study. Three primary themes were generated: (1) Recipients: innovations emerged as approaches to communicating discharge recommendations changed (in-person to virtual) and strong patient/family preferences to discharge to the home challenged collaborative goal setting; (2) Context: the ability of rehabilitation clinicians to innovate and the form of innovations were influenced by the broader hospital system, interdisciplinary team dynamics, and policy fluctuations; (3) Innovation: emerging innovations in discharge processes included perceived increases in team collaboration, shifts in caseload prioritization, and alternative options for post-acute care. Conclusions Our findings reinforce that rehabilitation clinicians developed innovative strategies to quickly adapt to multiple systems-level factors that were changing in the face of the COVID-19 pandemic. Future research is needed to assess the impact of innovations, remediate unintended consequences, and evaluate the implementation of promising innovations to respond to emerging healthcare delivery needs more rapidly.


Background
2][3] After COVID-19, discharge decision-making fundamentally changed as patients sought to avoid post-acute care facilities by discharging to home and the ability to provide necessary care in the home was hampered by ongoing, COVID-19 exacerbated industry challenges including an undervalued workforce and insu cient sta ng. 4-7Yet, we do not have a deeper understanding of how rehabilitation clinicians innovate in the face of external pressures to the health care system.This information has the potential to generate hypotheses to test changes to models of transitional care and inform measurement of unintended consequences (e.g., costly rehospitalizations or multiple, unnecessary transitions in care).
Given the rapid and evolving nature of the COVID-19 pandemic, a Learning Health System (LHS) approach is needed to study how pandemic-induced changes in uenced the emergence of innovation in rehabilitation clinicians' approaches and recommendations for hospital discharge.][10][11][12] The Veterans Health Administration (VHA) is the largest integrated health system in the United States and has communicated a vision to adopt LHS approaches into all aspects of research, clinical care, education, and emergency preparedness to optimize care and outcomes for over 9 million Veterans served. 9,10,13Thus, we wanted to explore VHA rehabilitation clinicians' perceptions of hospital discharge and transitions of care to identify emerging innovations that could inform future work evaluating the impact of promising innovations and spread or scale-up.
The continuous learning cycle supported through a LHS lens allows us to translate our approach to identifying and exploring emerging innovations-across a variety of clinical disciplines, settings, and systems-closer to real-time, thus allowing for more rapid and informed responses to system stressors.The COVID-19 pandemic is but one example of an external pressure and innovations in discharge decisionmaking are likely to occur again, particularly in the face of technological advances and possible postpandemic reforms in healthcare.With our current focus on hospital discharge, understanding organic innovation is a critical element to move forward with research and quality improvement initiatives to ensure safe, cost-effective, and patient-centered care transitions during the pandemic and beyond.Therefore, the aim of this qualitative study was to identify factors in uencing the emergence of innovation in rehabilitation clinician's hospital discharge decision-making during the COVID-19 pandemic.Our study's overarching focus was on the data to knowledge aspect of LHS, by which we used qualitative approaches to identify emerging innovations and perceptions of best practices in hospital discharge recommendations and transitions of care to inform future evidence and implementation of knowledge to practice.

Study Design
We used the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to guide our qualitative study. 14,15i-PARIHS considers facilitation a central component to aligning the innovation, recipients, and context for successful implementation.However, in the present study we did not operationalize facilitation because our goal was to identify organic innovation around discharge decision making (data to knowledge) rather than to evaluate implementation of a speci c innovation (knowledge to practice).The i-PARIHS framework examines the interactions among the recipients involved, contextual factors, and the potential clinical innovation.In i-PARIHS innovation is traditionally de ned as the intervention characteristics, including the complexity of the intervention, relative advantage compared to current practice or another intervention, usability, and evidence to support the intervention (e.g., research-based evidence, clinical experience, and patient preferences).In this study, innovation consisted of practices or approaches that organically emerged during the COVID-19 pandemic to manage hospital discharge decision-making and processes. 14,15The i-PARIHS construct recipients includes characteristics of the people who are affected by the innovation including patients and care partners. 14,15Context includes aspects internal to the organizational setting including leadership support, culture, organizational priorities, evaluation and feedback processes, and learning networks.Context also includes aspects external to the organization, such as policy drivers and priorities, incentives and mandates, and inter-organizational networks. 14,15

Participants
We used convenience sampling to recruit occupational therapists (OTs), occupational therapist assistants (OTAs), physical therapists (PTs), and physical therapist assistants (PTAs) who spend at least 25% of their time providing acute or post-acute care service in the Veterans Affairs (VA) Health Care System.An initial recruitment letter was sent out to rehabilitation clinicians in Minneapolis VA Health Care System (MVAHCS), where co-authors have a relationship with clinical leadership.We then used a snowball technique 16,17 to supplement our recruitment efforts by expanding beyond the MVAHCS to other VAs.Informed consent was obtained prior to data collection.

Data Collection
Qualitative data were collected from rehabilitation clinicians using semi-structured interviews conducted between May 2022 and August 2022.Interviews were conducted virtually.Interview participants self-reported descriptive characteristics that included discipline and years of practice.Union rules prohibited collection of any other demographic information (e.g., sex, race/ethnicity, age, highest degree earned) and recording or transcription of interviews.The interview guide (Table 1) was developed through an iterative, team-based approach and informed by expert input from key informants at the MVAHCS (two of whom participated in the interviews), a review of relevant literature, [18][19][20] and the i-PARIHS framework. 14,15Semi-structured interview procedures included a welcome, introduction, study purpose, interview goals, and a statement of con dentiality.The goal of the interview was to have rehabilitation clinicians provide detailed descriptions of their discharge decision making process and perceptions of the patient's transition from hospital to home, which could then be further analyzed within the i-PARIHS framework.During interviews, two members of the research team were present with one conducting the interview and the other taking extensive eld notes.
These two members of the research team met immediately after the interview to collaboratively review the eld notes, revise notes for accuracy of participant comments, and document immediate impressions.

Data Analysis
We used a rapid qualitative, deductive team-based approach 21,22 informed by directed content analysis. 23,24rapid qualitative approach 21,22 was employed as the pandemic and associated changes to the healthcare system persist and the insights gathered are timely and pertinent.Insights could be of immediate value by in uencing the content and utility of research and quality improvement in this area as well as by informing decision making in real-time regarding potential resource needs and promising approaches that could be scaled quickly to address ongoing system capacity challenges.Directed content analysis uses a prede ned framework (in this case i-PARIHS 14,15 ) to guide data collection, analysis, and interpretation. 24 used the constructs outlined in i-PARIHS (recipients, context, and innovation) to guide deductive themes and were also open to emergent themes.For analysis, we compiled extensive eld notes into a matrix for analysis (Microsoft Excel).The rows consisted of participants and columns represented the pre-identi ed categories mapped to the interview guide questions.Once all data was organized for each participant, the data was transferred to a word document (Microsoft Word) where repetitive data was removed.Three members of the research team (AMG, MJM and JPW) met bi-weekly to iteratively discuss and analyze the accruing data by deductively categorizing the raw data into prede ned themes by timepoint (pre-pandemic versus COVID-19 era) and discussing the potential for emerging themes or the need to collapse themes.
During this time, the team also identi ed representative eld note excerpts for emergent themes.Finally, the multi-disciplinary research team met bi-weekly to discuss resulting themes and how they compared or contrasted across timepoints.Saturation was de ned by the absence of new and emerging themes within the data. 25 exivity and Rigor This qualitative study followed the consolidated criteria for reporting qualitative research checklist (COREQ) to ensure the rigor of the study design, conduct, and interpretation of ndings. 26Prior to conducting any interviews, researchers (HJH, AMG, NB) were trained by co-author JPW-including completing a practice interview-to ensure consistency with qualitative interview processes.As a form of member checking, we discussed a draft table of results with three participants to ensure trustworthiness of our rapid qualitative analysis of ndings. 16,17,27During this member check, participants provided feedback on near completed qualitative ndings, voiced agreement or disagreement, as well as provided additional context for our ndings.These data were then used to nalize our qualitative results.

Role of Funding Source
The funders played no role in the design, conduct, of reporting of this study.

Results
We collected data from 23 rehabilitation clinicians (PT/PTA: 11; OT: 12) across 10 VHA facilities.No OTAs were recruited.The mean number of years working as a rehabilitation clinician was 13.7 (SD = 6.4; range 5-24 years) with the mean number of years working in the VHA system at 11.3 (SD = 6.7; range 1-23 years).
For each of the i-PARIHS constructs, we identi ed primary themes emerging from our qualitative data.The primary theme for recipients was "patient & care partner needs."The primary theme for context was "system & personnel needs", and the primary theme for innovation was "discharge processes & decision making."Table 2 outlines exemplar excerpts from our eld notes.The recipients construct of i-PARIHS was encapsulated by the primary theme of patient and care partner needs.This theme relates to the receipt of and potential participation in hospital discharge decision-making by patients and their care partners.Two nested sub-themes, representing differing approaches to meeting the diverse, modi able (or not), and potentially independent needs of patients and care partners included planning and communication and the complex nature of needs.
Planning & Communication.Pre-pandemic, interviewees said they relied on in-person communication with care partners to understand a patient's social support system including care partner availability, safety concerns, and additional services already in place.Additionally, in-person communication with care partners allowed for discussion of their preferences for and con dence in providing recommended care to the patient following hospital discharge.Participants then integrated this information with the patient's functional Complex Nature of Needs.Pre-pandemic, rehabilitation clinicians described the active engagement of patients and care partners in collaborative goal setting to support autonomy in both the patient's ultimate decision to go with or against discharge recommendations and the potential need for a higher level of care after hospital discharge (e.g., memory care or long-term care placement).In some complex situations, patient autonomy was in uenced by insurance coverage or environmental needs (e.g., cases where a patient was experiencing homelessness or lived in an unsafe housing situation).When talking about the COVID-19 era, participants indicated that patient preferences to discharge home meant reliance on home health care and services that were experiencing sta ng shortages.Participants suggested such staff shortages meant patient may have unmet needs prior to hospitalization that persist following discharge with added gaps in care and services to meet any new needs arising from recent hospitalization.
Context: System & Personnel Needs context construct of i-PARIHS was captured by the primary theme of system and personnel needs.This theme relates to the environment in which the health care system and rehabilitation clinicians operated in to make and enact discharge planning and decisions.Participants described different contextual factors in uencing hospital discharge decision making pre-pandemic versus the COVID-19 era, thus emergent subthemes included system in uence on clinician practice, the team role of rehabilitation clinicians, and pandemic-related uctuations in practices, processes, and policies.Practices, processes, and policies generated in response to the pandemic emerged as a subtheme that was unique to the COVID-19 era.
System In uence on Clinician Practice.Pre-pandemic, participants cited pressure to get patients out of the hospital and to the next level of sub-acute care for rehabilitation, often sub-acute rehabilitation, to increase the time needed to plan for a safe discharge home.Documentation was cited as essential to justifying rehabilitation clinicians' decisions surrounding appropriateness for further rehabilitation (acute or subacute), the need for additional services, and recommendations to ensure the safest discharge possible.
During the COVID-19 era-speci cally in the initial stages of the pandemic-some participants indicated they were operating under the assumption that patients need to discharge home, even in cases where they would have recommended short term rehabilitation for the same patient in a pre-pandemic scenario.This perceived pressure to discharge to home during the COVID-19 era created tension as clinicians grappled with the current state of post-acute care, speci cally the impact of sta ng shortages on home health care quality and timeliness.
Team of Rehabilitation Clinicians.Some participants felt that members of rehabilitation team were often the last ones invited to join in the discharge planning and decision-making process.These last-minute requests for assessment often left rehabilitation clinicians scrambling to set up home safety evaluations and care partner training.In some cases, participants felt their recommendations were the only thing keeping a patient from discharging to situation that was unsafe or where needs were not going to be met and readmission to the hospital was inevitable.Participants described delivering continuing education to interdisciplinary clinicians to address late involvement of rehabilitation clinicians and promote early and appropriate involvement of the rehabilitation team.Participants described their pre-pandemic role as primarily acute care assessment.During the COVID-19 era, some participants talked about a shift from their pre-pandemic assessment role to a sub-acute model of care-termed "Rehab in Place.""Rehab in Place" was described as daily treatment while hospitalized with a discharge goal directed at home.Some participants reported that this shift created tension in work roles as work ow (e.g., triaging) and resources (e.g., sta ng to provide treatments 6 to 7 days per week) needed to change to adequately support such a paradigm shift.
Participants talked about how the COVID-19 pandemic initially made discharge to rehabilitation facilities di cult due to outbreaks and patient/family fears of contracting the virus at a communal facility.These di cult placements led to longer hospitalizations and adjustments to plans of care (i.e., frequency of acute services) provided by rehabilitation clinicians; as a result, clinicians perceived elevated scrutiny from higher levels of leadership to either "Rehab in Place" with a higher frequency of services or develop alternative options for discharge.
Pandemic-Related Fluctuations in Practices, Processes, and Policies.During the COVID-19 era, participants reported high stress and emotional burden due to various communication breakdowns regarding visitor policies, personal protective equipment policies, outbreak status, changing public health recommendations.
While these changes in practice, processes, and policies have evolved with the pandemic, some participants felt rehabilitation teams were not given the chance "to breathe" and adjust to contextual changes in acute care delivery.Some participants spoke about the changes to work ow and resources as sources of tension between clinicians and organizational leadership.

Innovation: Discharge Processes & Decision Making
The innovation construct of i-PARIHS was portrayed by the primary theme of discharge processes and decision making that emerged and evolved with the onset of the COVID-19 pandemic.Participants described different approaches to hospital discharge decision making pre-pandemic versus the COVID-19 era, with noted transformations (innovation) occurring because of contextual and recipient factors arising from the COVID-19 era.Emergent, nested sub-themes included interdisciplinary collaboration; prioritization of work ow and caseloads; and reducing readmission risk.
Interdisciplinary Collaboration.Pre-pandemic, participants described the complex decision-making process that requires a high level of clinical reasoning to sift through the interaction between a patient's individual (e.g., falls risk, cognition, health literacy), social (e.g., caregiver support), and environmental (e.g., home environment, transportation) factors.Interdisciplinary collaboration was stated as a key component to making discharge recommendations.During the COVID-19 era, most participants talked about improved inter-and intra-disciplinary communication and collaboration through the expanded capacity of virtual communication platforms (e.g., Microsoft Teams, virtual care platform) that were newly implemented in the federal system.While face-to-face interactions were limited, chat and calling features on a secure network allowed for quick responses and virtual hand-offs.As noted previously in the section on Planning and Communication, the absence of family or care partners to con rm or provide accurate information to inform discharge process and decisions was a signi cant challenge to meeting patient and family needs.As a result, during the COVID-era most participants described enhanced interdisciplinary team coordination (formal and informal) that occurred to make sure everyone was on the same page in terms of what information is provided (by patients, family, or care partners) and how it impacts the discharge decision.
Participants spoke about how the pandemic-accelerated expansion of virtual care options allowed clinicians to make discharge decisions that would ensure patients would receive the necessary follow-up care and support services.Participants described the continuity of care that could be provided by the VA when VA physical and occupational therapists could provide virtual care to Veterans in their home following hospitalization.
Prioritization of Work ow & Caseloads.Pre-pandemic, most participants described work ows where patients with imminent hospital discharges were prioritized to receive visits or services versus those awaiting placement and needing a sub-acute level of care.After high-priority cases were seen, rehabilitation clinicians' built-in work ows allowed for follow-up to capture the natural progression of recovery and potential changes in functional status that could in uence updates to discharge recommendations.Participants spoke about how follow-up allowed for reassessment of the patient's progress and function to determine what level of sub-acute rehabilitation care may (or may not) be needed and the most appropriate discharge location.For patients where a discharge directly to home was considered, participants indicated caregiver presence was crucial along with the willingness to complete home physical or occupational therapy to maximize function and ability to complete activities of daily living.
During the COVID-19 era, some participants spoke about earlier discharge planning and decision-making for more complex patients for whom discharge placement would be di cult.They acknowledged that patients with di cult placements was not a new challenge, but the pandemic has made such placements and the increased hospital lengths of stay more visible in an era where hospital stays may be longer due to limited or unavailable post-acute resources.When discussing the COVID-19 era, participants described adjusting the frequency of services per week in two scenarios.The rst scenario was a sub-acute model of care where they were providing treatment 5 days per week to patients who would be going home, and pre-pandemic would have discharged to sub-acute care.Pre-pandemic plans of care in the hospital setting for patients waiting for sub-acute care was 1-3 days per week.In the second scenario, participants described decreasing plans of care (visits per week) in patients waiting for sub-acute care to get to more acute patients.
Reducing Readmission Risk.Pre-pandemic, most participants talked about the default recommendation being sub-acute rehabilitation to ensure the patient's overall daily function was maximized prior to return home.Some participants indicated that multiple hospitalizations or recent readmissions signaled a need for further conversation with the patient and interdisciplinary team to re ect on what worked and did not work in the previous discharge plan.Participants spoke about the need for care partner support and willingness to complete home rehabilitation as an essential component of discharge making when considering a safe discharge to home.
Many participants noted a shift during the COVID-19 era towards more discharge recommendations to home with supports and services.This shift has varied throughout the pandemic due to restrictions in rehabilitation facilities being lifted and the availability of vaccines.Some participants described maintenance of this type of mindset to promote "Aging in Place," while also indicating that other members of their team have slipped back to the previous default of discharge to sub-acute rehabilitation.Some participants indicated their discharge decision-making included more "thinking outside the box."Participants described a wider array of discharge options that balanced tensions and strains of the pandemic on health and social supports.For example, one participant talked about how pre-pandemic the discharge recommendations were limited to 3-4 options (home, home with home health rehabilitation, sub-acute rehabilitation, and acute rehabilitation unit).Now in the COVID-19 era, the participant indicated more rehabilitation recommendation options were created to innovatively expand safe discharge options for home (e.g., home with durable medical equipment, home with skilled or unskilled care).However, some participants noted that patients may "fall through the cracks" due to the lack of follow-up to ensure equipment was received, home services and supports were started in a timely manner, and rehabilitation was initiated.
During the pandemic, participants indicated teleworking allowed time to reach out to patient's following hospital or post-acute discharge to ensure equipment and home services were in place and assess whether the patient or care partner had additional questions.One participant noted that during the COVID-19 era, supply chain issues for durable medical equipment (e.g., standard wheelchair, lifts) have led to creative solutions to ensure patients have what they need as an alternative "bridge" to the equipment for safe discharge home.For example, rehabilitation clinicians leveraged equipment that might be available in satellite clinics to ensure patients were able to get critical needs, such as a walker or crutches, before discharging home.Another example was increased communication and collaboration with family-outside of the primary care partner-on a plan to safely assist in the home until lift equipment arrived.

Discussion
This qualitative study found factors that in uenced the emergence of innovation in hospital discharge decision-making during the COVID-19 era, thereby informing the data to knowledge aspect of LHS.For this study, we applied the i-PARIHS framework in a novel way to identify organic clinical innovation developed during hospital discharge decisions when the system was stressed by the COVID-19 pandemic.While i-PARIHS is traditionally used to identify barriers and facilitators to implementation of a speci ed innovation, we used the framework to identify emerging innovations in response to the pandemic.Additionally, we used i-PARIHS to understand and describe the underlying context and recipient factors that potentially drove these innovations.Such an application of i-PARIHS allows future research to consider alternative approaches to evaluating emerging innovations that have the potential to translate knowledge into practice.Breton and colleagues utilized a similar approach, although not with i-PARIHS, to qualitatively examine how the pandemic modi ed the organization and processes of primary care and how those were implemented for continuous quality improvement. 28As such, our study adds to the literature by depicting a health care system's response and emerging innovation in discharge decision making that fostered creative solutions to existing, new, and evolving issues with hospital discharge during the COVID-19 era.
We identi ed similar challenges during the COVID-19 era as those described by other qualitative studies 29,30 including reports of reduced communication between clinicians and care partners, a focus on decreasing hospital lengths of stay, patients opting to go home rather than sub-acute rehabilitation, and ongoing stress and emotional burden with ever changing policies/practices.Our ndings are also consistent with experiences of other healthcare professionals during the pandemic. 31,32Other qualitative studies of frontline providers during the pandemic described positive experiences that emerged from the challenges such as feeling part of something bigger than themselves and being valued as healthcare professionals. 32,33These experiences align with our ndings of innovation in the midst of a systemic stressor.Our study found that hospital discharge decision making as part of hospital care is evolving as the pandemic persists and some changes were perceived as positive by rehabilitation clinicians.
The ndings from this study highlight how innovations in response to external stressors (pandemic) work to potentially improve patient outcomes and whether unintended consequences of such innovations arise.
Future research is needed to evaluate the impact of the following perceived innovations identi ed by participants to determine the patient, clinician, and system-level outcomes: increased ease of team collaboration due to virtual options, changes in caseload prioritization in the hospital setting, increased consideration of transitions of care directly to the home, and the increased availability and accessibility of virtual care in the home.Many of these innovations align with prioritization of "Aging in Place" which is known to have many bene ts from patients. 34,35It may be that clinicians and systems saw rsthand the bene ts of "Aging in Place" and perceived the risks of discharging home were not as high as previously assumed.Identi cation and evaluation of unintended consequences that are not deliberate or foreseen are needed to fully understand the impact innovations can have on multiple outcomes. 36For example, a shift toward a "Rehab in Place" model of care may have implications for sta ng structures and patient perceptions of care.There is also a need to recognize the toll of the pandemic on rehabilitation clinicians' mental health and collective trauma from providing care during the pandemic. 37Staff stress and burnoutdespite innovations-is a necessary factor to consider when potentially rede ning the role of rehabilitation clinicians in the hospital setting.
Our ndings also highlight the importance of implementation frameworks-such as i-PARIHS-in identifying factors that hinder or facilitate innovations that improve health service delivery and patient outcomes.
Identifying and understanding these factors can inform future studies along the research continuum from effectiveness to implementation trials.This study's strength is that it provides insight into evolving recipient and context factors that fostered innovation and contributes to the data to knowledge part of an LHS cycle.
With a LHS lens, we applied the i-PARIHS framework in a novel way to identify organic clinical innovation developed during hospital discharge decisions when the system was stressed (in this case by the COVID-19 pandemic).The application of this method transcends disciplines, settings, communities, and systems as the need to iteratively evaluate and continuously learn is crucial to healthcare transformation and the overall vision of optimizing patient and population outcomes.

Limitations
A few limitations of this study should be noted.First, the participants were recruited from and provided care in the VA health care system and, thus, the results may not be immediately transferrable to other non-VA health care systems.The COVID-19 pandemic created a natural experiment where all health care systems were stressed and, thus, responses to such stress may be similar across systems.In addition, we choose the VHA given its vision to implement LHS principles and the infrastructure it is creating to support this vision.Second, due to union stipulations we were unable to record interviews or collect demographic data on participants other than disciplines and years of clinical experience.To address this, we used member checking to ensure we accurately captured the data.In terms of demographic data, the American Physical Therapy Association's most recent data to date on members (2016-2017) indicates a majority identify as female, white, non-Hispanic with most having at or above a doctorate level terminal degree. 38

Conclusions
Understanding the experiences of rehabilitation clinicians providing care and engaging in hospital discharge decisions prior to the pandemic and during the COVID-19 era is essential to informing real-time resource needs and promising approaches that can be adapted, implemented, evaluated, and scaled quickly in response to system stressors.Importantly, the information gathered by this qualitative study provides foundational data for future research and learning health system efforts focused on improving transitions from the hospital to the next level care.The experiences captured by rehabilitation clinicians suggest responses to the ongoing pandemic and future, unforeseen stressors can be innovative and potentially a positive change to the current status quo.
ability and environmental factors to formulate a safe discharge recommendation that met both patient and care partner needs.Pre-pandemic, participants described communicating typical recommendations for subacute rehabilitation stay (e.g., skilled nursing facility) following hospitalization to patients and care partners to allow increased time for the interdisciplinary team, patient, and family to adequately plan for appropriate and safe discharge.During the COVID-19 era, participants maintained that communication with care partners remained an essential component of care despite di culty communicating and providing hands-on training with care partners due to visitor restrictions.As such, communication with family or care partner occurred via phone or video which participants indicated may lead to miscommunications and misunderstanding of a patient's current level of function and corresponding needs.A few participants talked about how the family needed to see the patient's challenges in-person to fully understand what the patient's needs would be at hospital discharge by comparing to his or her prior level of function.Additionally, visitor restrictions made hands-on training and subsequent planning for safe discharge challenging.One participant described providing care partner training over the phone and indicated it was ineffective because the clinician was unable to model the training (e.g., where to stand, how the clinician might assist with verbal cues, home set-up modi cations).
AbbreviationsVA Veteran Affairs VHA Veteran Health Administration LHS Learning Healthy System i-PARIHS integrated Promoting Action on Research Implementation in Health Services OT Occupational Therapist OTA Occupational Therapist Assistant PT Physical Therapist PTA Physical Therapist Assistant MVAHCS Minneapolis Veteran Affairs Health Care System

Table 1
Interview guide.1.Please tell me about your experience making discharge recommendations for patients in the COVID-19 era (i.e., currently).

Table 2 i
-PARIHS constructs and emergent themes by pre-pandemic and COVID-19 era time frames with exemplar eld note summaries.
• Higher reliance on under-staffed home health care & services because of patient or care partner preference to discharge home meant unmet needs may be present prior to hospitalization and persist post-discharge with additional gaps in new needs CONTEXT: System & Personnel Needs