Recently, we partnered with Massachusetts Senior Care Association to share results of a Special Innovation Project at our “Outcomes Congress” with over 30 individuals from a range of settings.
Project participants came together to highlight and learn from the success of key elements adapted from Project RED to support discharge from skilled nursing facilities back into the community.
The project’s success most notably included sustained readmission reduction following discharge home from the skilled nursing facility. In addition to the review of successes were presentations from Southcoast Health and MA Senior Care leadership. A cross-setting panel took questions from the audience and reviewed key takeaways, obstacles, and lessons learned.
Don’t worry if you were unable to attend. We’ve collected all of the resources shared that day, including this video explaining the Project RED process and showcases a provider and patient success story.
Improving Nursing Home Discharges Back to the Community Toolkit
Our Toolkit includes everything you need to implement tools to enhance your current discharge process. It contains two types of materials:
- Reference tools to assist with implementation of Project RED elements by incorporating them into current processes
- Tracking documents that measure success of the project and allow for evaluation of the impact on utilization and readmissions
Don’t want the whole kit?
The Table of Contents includes an explanation of each tool included, how to use it, and its file name. All materials are meant to enhance your current process by using evidence based materials shown to improve patient discharge outcomes and reduce readmissions.
- Process Map
- Overview Process & Roles: Re-Engineered Discharge for Skilled Nursing Facilities
- ASAP and VNA Referral Workflow
- Understanding & Enhancing Role of Caregivers
- Assessing Family Caregivers: A Guide for Health Care Providers
- What Do I Need as a Family Caregiver?
- RED Discharge Preparation Workbook: Nursing Home to Community
- Patient-Level Project RED Checklist
- Sample Script: Post Discharge Follow-Up Phone Call
- Documentation Form: 2 day Follow-up Phone Call
- Documentation Form: 30 day Follow-up Phone Call
- Portal Guide
- Case Studies
- Moderator Guide