A variety of forces are pushing hospitals to improve their discharge processes to reduce readmissions. Researchers at the Boston University Medical Center (BUMC) developed and tested the Re-Engineered Discharge (RED). Research showed that the RED was effective at reducing readmissions and posthospital emergency department (ED) visits. The Agency for Healthcare Research and Quality contracted with BUMC to develop this toolkit to assist hospitals, particularly those that serve diverse populations, to replicate the RED.

Select for the Taking Care of Myself: A Guide for When I Leave the Hospital, a booklet for patients based on the RED Toolkit.

Related Content

Case Study: Memorial Hospital Uses AHRQ Resources to Cut Readmissions, Promote Patient Self-Management
Case Study: AHRQ's RED Toolkit Inspires Improved Patient Discharge at Nacogdoches Memorial Hospital
Case Study: AHRQ's RED Toolkit Leads to Lower Readmissions, Better Care Transitions in Two Texas Hospitals
Read about lessons learned from implementing RED in ten hospitals across the country in, "How Hospitals Reengineer Their Discharge Processes to Reduce Readmissions" Journal Healthcare Qual 2015 May 13. [Epub ahead of print]

Prepared by:

Boston University

Brian Jack, MD

Michael Paasche-Orlow, MD, M.P.H.

Suzanne Mitchell, MD

Shaula Forsythe, M.P.H.

Jessica Martin, M.A., M.P.H.

Agency for Healthcare Research and Quality

Cindy Brach, M.P.P.

Contract No. HHSA290200600012i

Acknowledgments

Tool 1: Overview

Purpose of the Toolkit

Reasons To Re-Engineer Your Discharge Process

Impact of RED

New and Improved RED Toolkit

References

Tool 2: How To Begin the Re-engineered Discharge Implementation at Your Hospital

Purpose of This Tool

Eleven Steps To Implement the Re-Engineered Discharge

Step 1: Make a Clear and Decisive Statement

Step 2: Identify Your Implementation Leadership

Step 3: Analyze Your Readmission Rates and Determine Your Goal

Step 4: Identify Which Patients Should Receive the RED

Step 5: Create Your Process Map

Step 6: Revise Current Discharge Workflow To Eliminate Duplication

Step 7: Assign Responsibility for RED Components

Step 8: Train Discharge Educators and Followup Telephone Callers

Step 9: Decide How To Generate the After Hospital Care Plan

Step 10: Provide the RED for Diverse Populations

Step 11: Plan To Measure the Progress of RED Implementation

Sample Training Agenda

References

Tool 3: How To Deliver the Re-Engineered Discharge at Your Hospital

Purpose of This Tool

Role of the Discharge Educator

The After Hospital Care Plan

What Are the Components of the After Hospital Care Plan?

What Is the Patient Information Workbook and the RED Workstation?

Steps To Deliver the In-Hospital RED Components

Obtain and Review Patient Information From Medical Records

Confer With the In-Hospital Medical Team

Arrange To Meet With Patient, Family, and Other Caregivers

First Meeting With the Patient

Tool 3 Continued

Follow Up on Test or Lab Results That Are Pending at Discharge

Organize Postdischarge Medical Equipment and At-Home Services

Identify the Correct Medicines and a Plan for the Patient To Obtain Them

Reconcile the Discharge Plan With National Guidelines

Teach the Content of a Written Discharge Plan in a Way the Patient Can Understand

Assess the Degree of Patient Understanding

Review What To Do if a Problem Arises

Postdischarge Components of the RED

Transmit the Discharge Summary to the Postdischarge Clinician

Provide Telephone Reinforcement of the Discharge Plan

Staff a Discharge Educator Help Line

Other Teaching Opportunities Included in the AHCP

Components of After Hospital Care Plan (AHCP)

Example After Hospital Care Plan (AHCP)

AHCP Template for Manual Creation: English-Speaking Patients

Template for Manual Creation of the AHCP: Spanish-Speaking Patients

RED Discharge Preparation Workbook

Contact Sheet

Examples of Diagnosis Pages

Tool 4: How To Deliver the Re-Engineered Discharge to Diverse Populations

Purpose of This Tool

Role of Culture, Language, and Health Literacy in Readmissions

Culture and Its Relationship to Readmissions

Language and Its Relationship to Readmissions and Patient Safety

Health Literacy and Its Relationship to Readmissions

Preparations for Providing the RED to Diverse Populations

Hiring Bilingual, Bicultural Discharge Educators

Providing Cultural and Linguistic Competence Training

Ensuring Availability of Interpreter and Translation Services

Overview of Delivering the RED to Diverse Patient Populations

Getting Started With the RED for Diverse Populations

Assessing Communication Needs

Using Nonverbal Communication Styles While Teaching the RED

Understanding Health Beliefs, Alternative Healers, and Attitudes About Medicines

Understanding Patients and Communicating Across Differences

Teaching the AHCP to Patients With Limited English Proficiency

Using Qualified Medical Interpreters To Create and Teach the AHCP

Working With Qualified Medical Interpreters

Accessing Interpreters by Phone and Video

Handling Patient Refusal of Language Assistance

Understanding the Role of Family and Community

Additional Considerations

Dietary Patterns

Religious Observances

Gender Preferences

Sexual Orientation and Gender Identity

Mental Health

References

Tool 5: How To Conduct a Postdischarge Followup Phone Call

Purpose of This Tool

Preparing for the Phone Call

Ensure Continuity of Care

Learn How To Confirm Understanding

Review Health History and Discharge Plans

Check Accuracy and Safety of Medicine Lists

Identify Problems Patients Could Have With Medicines

Arrange for Interpreter Services

Conducting the Phone Call

Whom and When To Call

What To Say

Documenting Your Call

Communicating With the PCP

Contact Sheet

Postdischarge Followup Phone Call Script (Patient Version)

Postdischarge Followup Phone Call Documentation Form

Phone Call Role Play

Tool 6: How To Monitor RED Implementation and Outcomes

Purpose of This Tool

Getting Started

Selecting and Specifying Measures

Implementation Measures

Is the RED Being Delivered to Target Patients?

Is the Correct Information Being Collected?

Is Evidence-Based Care Being Delivered?

Is Appropriate Followup Care Being Arranged?

Are Patients Being Prepared for Discharge?

Are Patients Receiving Postdischarge Care?

Selecting Implementation Measures

Outcome Measures

Hospital Reutilization Measures

Connections With Outpatient Providers

Knowledge for Self-Management

Patient Satisfaction

Collecting Data

RED Workbooks and Contact Sheets

Electronic Health Records and the RED Workstation

Patient Surveys

Measurement Timing and Frequency

Other Means of Monitoring the RED

Root Cause Analyses

DE Help Line Logs

Direct Observation

Taking Action

Summary

Discharge Measures Used by Other Organizations

How CMS Measures the "30-Day All Cause Rehospitalization Rate" on the Hospital Compare Web Site

Patient Outcome Survey (mailed version)

Patient Outcome Survey (phone version)

References

Tool 7: Understanding and Enhancing the Role of Family Caregivers in the Re-Engineered Discharge

To augment the Re-Engineered Discharge Toolkit, Carol Levine and Jennifer Rutberg of United Hospital Fund and Brian Jack and Ramon Cancino of Boston University School of Medicine have developed Tool 7: Understanding and Enhancing the Role of Family Caregivers in the Re-Engineered Discharge

(PDF File, 428.5 KB).

The authors of this guide are responsible for its content. The opinions expressed in this document are those of the authors and do not reflect the official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services. Statements in the guide should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Acknowledgments

We would like to thank the following consultants who gave feedback on earlier versions of this tool: Linda Barnes, MD; William Barron, MD; Frances Bonardi, RN; Erica Dobson, PharmD; Luke Hansen, MD; Steve Martin, MD; Carol Mostow, LICSW; Victoria Parker, DBA; and Jeff Ring, MD

We would also like to thank the hospitals who implemented the RED using an earlier version of this toolkit and provided insights that were used in finalizing the toolkit.

Finally, we thank Carol VanDuesen Lukas, EdD, and Sally Holmes, MBA, from the Boston University School of Public Health for conducting interviews and compiling lessons learned.

Page last reviewed June 2015

Internet Citation: Re-Engineered Discharge (RED) Toolkit. June 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html