OpenPlacement Blog

Why Healthcare is in the RED (Re-Engineered Discharge Toolkit)

ToolboxDue 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:

Ascertain need for and obtain language assistance

  • Seek information about oral communication skills and English proficiency

  • Arrange for an interpreter and translations of written material as needed

Make appointments for follow up medical exams and post discharge tests/labs

  • 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

Plan for the follow up of results from lab tests or studies that are pending at discharge

  • Determine how results of pending lab tests will be communicated

Organize post-discharge outpatient services and medical equipment

  • 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

Identify the correct medicines and a plan for the patient to obtain and take them

  • 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

Reconcile the discharge plan with national guidelines

  • Ensure the plan meets the National Guidelines Clearinghouse recommendations

Teach a written discharge plan the patient can understand

  • Answer questions patients may have about discharge

  • Provide a plan that is easy to understand

Educate the patient about his or her diagnosis

  • Discuss with patient and caregivers the condition of the patient and what to do after discharge

Assess the degree of the patient's understanding of the discharge plan

  • Use methods such as Teach Back to ensure patients understand

Review with the patient what to do if a problem arises

  • Provide information such as contact numbers for those that can be reached if there is a problem

Expedite transmission of the discharge summary to clinicians accepting care of the patient

  • Have discharge summary delivered to other healthcare providers and AHCP no later than 24 hours after discharge

Provide telephone reinforcement of the discharge plan

  • 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.