Due to scrutiny of hospitals' readmissions rates, and new penalties being issued in order to encourage hospitals to improve their readmissions rates, many hospitals and other organizations are attempting to create new ways to improve readmission. This has begun by analyzing discharge policies and seeking creative means of improving them.
Developed by researchers at Boston University Medical Center, RED, the Re-Engineered Discharge Toolkit is aimed to help hospitals implement a plan to reduce readmissions. There are 12 components to the toolkit.
The components include:
Seek information about oral communication skills and English proficiency
Arrange for an interpreter and translations of written material as needed
Assess the need for follow ups with PCPs or specialists
Assist the patient in finding a PCP if he/she does not have one
Assess need for further testing
Educate the patient on the important of follow up appointments and tests
When making appointments for the patient consider preferences for location, ability to get to the location of the healthcare provider, insurance coverage, etc.
Ensure that the patient knows how to get to the locations of follow up visits and that adequate transportation is available
Determine how results of pending lab tests will be communicated
Work with the manager of the case to make sure that all necessary medical equipment is available for the patient and is of high quality
Determine the level of support the patient will have at home and assess any extra needs the patient will have as a result
Arrange at-home services as necessary
Work with the patient to ensure he/she is familiar with all of the medicines he/she will need to take
Determine what other medications or supplements the patient is already taking
Make sure the patient is comfortable with all of the medications prescribed and the regiment to take them
Ensure the plan meets the National Guidelines Clearinghouse recommendations
Answer questions patients may have about discharge
Provide a plan that is easy to understand
Discuss with patient and caregivers the condition of the patient and what to do after discharge
Use methods such as Teach Back to ensure patients understand
Provide information such as contact numbers for those that can be reached if there is a problem
Have discharge summary delivered to other healthcare providers and AHCP no later than 24 hours after discharge
Follow up with the patient several days after discharge via phone
Following this plan, hospitals should be able to dramatically lower their readmission rates while greatly improving the quality of care provided to patients.