Every year millions of patients are readmitted to hospitals, and many of those stays could have been prevented. The Re-Engineered Discharge (RED) Toolkit, funded by the Agency for Healthcare Research and Quality, can help hospitals reduce readmission rates by replicating the discharge process that resulted in 30 percent fewer hospital readmissions and emergency room visits.
This newly expanded toolkit provides guidance to implement the RED for all patients, including those with limited English proficiency and from diverse cultural backgrounds. By helping hospitals plan and monitor the implementation of the RED process, the toolkit ensures a smooth and effective transition from hospital to home.
RED, developed and tested by the Boston University Medical Center, consists of a set of 12 actions the hospital undertakes during and after the hospital stay to ensure a smooth and effective transition at discharge. These 12 actions have been proven to reduce hospitalizations and yield high rates of patient satisfaction.
The toolkit is a complete implementation guide consisting of seven tools, with five of them providing step-by-step instructions to jumpstart hospitals in this process. This has been recently adapted to address language barriers, cross cultural issues and disparities in healthcare communication and trust. These adaptations help organizations provide Culturally and Linguistically Appropriate Services (CLAS) and address the Communication and Language Assistance National CLAS Standards 5-8.
Is your organization providing CLAS or could your organizations improve by re-designing your discharge process utilizing RED? Take the GPQIN CLAS Checklist and Action Plan to identify opportunities to improve CLAS at your organization. Great Plains QIN modeled this assessment from the national Office of Minority Health Assessment. Use this checklist to measure where your organization is at in this journey, identify needs and develop an improvement plan to address the basic elements of the National CLAS Standards. Please keep in mind, there is no single correct way to implement the National CLAS Standards. The Assessment may take about 10 minutes to complete.
Nursing Homes & Skilled Nursing Facilities – Additional Information for You
We understand that readmissions are important to your organization with financial penalties or rewards with the Skilled Nursing Facility Value Based Program (VBP) measure to reduce 30 day all cause hospital readmissions.
If your organization has identified this as an opportunity for improvement, we encourage you to watch this short video explaining how RED can be used in the nursing home/SNF discharge of residents.
Access the Improving Nursing Home Discharges Back to the Community Toolkit (developed by Healthcentric Advisors). This guide includes a range of tools and resources to enhance your current discharge process. All materials are adapted for the nursing home setting, intended to enhance your current process and were developed from three main evidence-based resources:
• Project RED (Re-Engineered Discharge)
• Care Transitions Intervention Model®
• Gap analysis of participating nursing homes’ current discharge processes
Take a look, you may already be doing many of the interventions shown in this toolkit. However, the toolkit may provide new ideas to help reduce readmissions in your organization. Print and utilize the tools available, including:
- Admission Assessment Checklist
- Prepare for Discharge Checklist
- Discharge Plan Review
- Post discharge follow up
- Workflows
- After Care Plan
- Assessing family caregivers: A guide for healthcare providers
Please note; this toolkit was developed for Rhode Island; where it states to contact your local aging services access points, those are your local/community long-term support services and VNA is the home health services in that area. Disregard pages 45-49 HCA/Portal as we do not have a portal for use.
Additional Great Plains QIN Resources