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

August 22nd, 2013

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.


  1. Merilee Griffin August 22, 2013

    What’s the plan for a patient with dementia who can’t remember the instructions after getting home?

    1. Christy Rakoczy August 23, 2013

      Merilee – This is a great question and something worth talking about and bringing to light. In general and as I recommended in the above article the Teach-Back Method ( can be very effective when trying to make sure patients understand their discharge orders.

      That said, this obviously has limitations when working with someone with dementia. I have found this resource guide from the Family Caregiver Alliance to be extremely helpful:

      This is what they call the “Caregiver’s Guide to Understanding Dementia Behaviors.” I think some of the feedback and insights here can be very powerful. I hope this helps and thanks for your question!

    2. Detria Walker, PhD Geriatric Care Manager August 31, 2013


      This tool kit is a great plan of action for patient discharge. In my experience as a Home Health Geriatric Care Manager, patients with cognitive disabilities are discharged to a person who is managing their care (friend, family member). I provide gap services for patients being discharged home or back to a medical facility. The tool kit from Boston University is very similar to what I provide my patients. I hope I answered your question.

  2. Myranda Smith August 23, 2013

    Great ideas on how to reduce readmission rates in the future. Hopefully hospitals will start to implement these actions immediately since the healthcare bill in our country is sky high. We can use all the help we can get to reduce the costs of hospital expenses.

  3. Sarah Navarra August 27, 2013

    Private duty home care is also a great way to ensure the touch points above are adhered to. Caregivers can remind patients to take and fill meds, can prepare low sodium/ low cholesterol meals and assist with at home exercises. More importantly, they can be in the home to identify red flags and intercede any readmission by contacting the home care nurse, the patient’s PCP and/ or family when there is a questionable health issue instead of the patient calling 911 in a panic. Unfortunately, it’s my experience that hospitals and PCPs either don’t know the difference between home health and non-medical home care or they are just assuming the home health/ medical home care will refer private duty…but most often, they don’t. Unless the family asks for the extra help, they are never educated on the available resource.

  4. Deanna McClain November 29, 2013

    Is there a cost to the hospital for the RED toolkit?


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