Project ReEngineered Discharge (RED) lowers hospital readmissions of patients discharged from a skilled nursing facility
Abstract
Context Patients admitted to skilled nursing facilities (SNFs) have a high risk for rehospitalization.Objective The goal of this project was to implement Project RED in an SNF to increase patient preparedness for care transitions and lower rehospitalization rates in the 30 days after discharge from the SNF facility.Design Intervention study with historical control; phone survey 30 days after discharge from the SNF for data collection.Setting The study was conducted in an SNF admitting patients from acute care hospitals in Boston, MA.Patients or other participants A consecutive sample of patients in the SNF before (n = 524) and after initiation (n = 100) of the intervention. Participants had an average age of 80 (SD = 10), 67% were female, and 84% were non-Hispanic white. Phone surveys were completed with 88% of participants in each group.Intervention(s) We adapted Project RED for use in an SNF. This includes a comprehensive approach to transitions of care that includes creating and teaching a personalized care plan to patients and their families. Software facilitating these activities was integrated into the electronic medical record of the SNF; intervention activities were delivered by existing staff.Main outcome measure(s) The main outcome was hospital readmission within 30 days of discharge from the SNF. Secondary outcomes included attendance to a medical appointment within 30 days of discharge from the SNF and preparedness for care transitions as measured by a 6-item survey.Results The rate of hospitalization 30 days after discharge from the SNF for participants prior to the intervention was 18.9% and for participants during the intervention was 10.2%, P < .05. This remained significant adjusting for multiple potential confounders (P = .045). More patients in the intervention group had attended an outpatient appointment within 30 days of discharge (70.5% versus 52.0%, P < .003). In addition, intervention participants reported a higher level of preparedness for care transitions.Conclusions Patients in the intervention had a lower rate of returning to the hospital within 30 days of discharge from the SNF, were more likely to attend medical appointments, and were better prepared for their care transition.
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The Connect-Home framework posits that transitional care requires structures (e.g., staff training and tools in the electronic health record) to support time-limited processes designed to address care needs at home (e.g., safety, symptom management) and improve patient and caregiver outcomes.
“the framework posits that transitional care requires structures (e.g., staff training and tools in the electronic health record) to support the time-limited processes designed to address care needs at home (e.g., safety, symptom management) and improve patient and caregiver outcomes.23, 24”
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Using the Eco-Map and Ecosystems Perspective to Guide Skilled Nursing Facility Discharge Planning
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Depression and Coleman Care Transitions Intervention
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Reengineering Skilled Nursing Facility Discharge
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Transforming Health Care from Volume to Value: Leveraging Care Coordination Across the Continuum
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Integrated care transitions: emergency to primary health care
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E-Health Care: Promise or Peril for Chronic Illness
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Testing Re-Engineered Discharge Program Implementation Strategies in SNFs
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Coordinated-Transitional Care (C-TraC) for Veterans from Subacute Rehabilitation to Home
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- Authors
- Berkowitz, R. E., Fang, Z., Helfand, B. K. I., Jones, R. N., Schreiber, R., & Paasche-Orlow, M. K.
- Affiliations
- Emory University (US)
- Hebrew SeniorLife (US)
- Corresponding author
- Berkowitz, Randi E.
- Venue
- Journal of the American Medical Directors Association
- Publisher
- Elsevier BV
- Published
- 2013-10
- Volume
- 14
- Issue
- 10
- Pages
- 736-740
- ISSN
- 1525-8610 (ISSN-L)
- OpenAlex
- W1975581707
- Cited by
- 128
- References
- 16
- Citations by year
- 2026: 2 · 2025: 6 · 2024: 10 · 2023: 7 · 2022: 9 · 2021: 6 · 2020: 9 · 2019: 12 · 2018: 16 · 2017: 17 · 2016: 14 · 2015: 12 · 2014: 6 · 2013: 2
- FWCI
- 11.25
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of the American Medical Directors Association (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Keywords
- hospital readmission, skilled nursing facilities, care transitions, discharge planning, individualized care plans, patient readiness, older adults, quality improvement intervention
- MeSH terms
- Aged, Aged, 80 and over, Ambulatory Care, Boston, Female, Hospitalization, Humans, Male, Patient Care Planning, Patient Discharge, Patient Readmission, Skilled Nursing Facilities, Case-Control Studies
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