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Reduction of 30-Day
Readmissions with Discharge
Readiness Tool (DCRT)
Ashtabula County Medical Center
Readmission Performance
Improvement Team
Jessica Fasano
Purpose
Purpose- to focus on decreasing 30-day
readmissions
Identify those at risk for readmission
Reviewing top 20 patients readmitted within
the past 6 months Identifying factors for
readmission
Development of plan based on diagnosis and
transitioncoordination of care
Multidisciplinary team includes TAC Home
Health physicians PTOT pharmacy Care
Management Quality and other outside
agencies
Challenges
bull Concerns with not being able to view
DC instructions in EPIC
bull Medication Reconciliation not complete
bull Clinic scheduling follow-up difficulty
bull Issue with needs addressed prior to
discharge
bull Communication from physician on
discharge
Discharge Readiness Tool
(DCRT)
bull Developed as a real-time EPIC based
tool that leverages nationally published
and studiedproven tools such as
Project RED and BOOST
bull It can also simulate a virtual care team
huddle signaling a patientrsquos readiness
for discharge
bull Intent is to give a visual overview
DCRT
DCRT 2
bull The Anticipated
Discharge Date order
helps communicate to
the team when a
provider plan to
discharge the patient
bull The use of this order
is encouraged
DCRT 3
bull If a patient has a
high risk score of
greater than 40 a
red banner will
appear at the top
of the tool It will
NOT calculate for
PEDS Hospice or
OB patients
DCRT 4
bull DCRT displays
information already in
documented in EPIC
in a concise format
and in real time
bull Each criteria on the
report identifies
Completed items (indicated
by a red yellow or green
icon)
Incomplete items that need
to be addressed
DCRT 5
bull If care coordinators have been
identified this information will appear
bull The problem list should be reconciled
at discharge and the status will now
appear on the tool
DCRT 6
bull The Health Literacy Barriers section may
display as an FYI No action is needed
bull Click on the hyperlink to view the
Readmission Risk Report
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
Purpose
Purpose- to focus on decreasing 30-day
readmissions
Identify those at risk for readmission
Reviewing top 20 patients readmitted within
the past 6 months Identifying factors for
readmission
Development of plan based on diagnosis and
transitioncoordination of care
Multidisciplinary team includes TAC Home
Health physicians PTOT pharmacy Care
Management Quality and other outside
agencies
Challenges
bull Concerns with not being able to view
DC instructions in EPIC
bull Medication Reconciliation not complete
bull Clinic scheduling follow-up difficulty
bull Issue with needs addressed prior to
discharge
bull Communication from physician on
discharge
Discharge Readiness Tool
(DCRT)
bull Developed as a real-time EPIC based
tool that leverages nationally published
and studiedproven tools such as
Project RED and BOOST
bull It can also simulate a virtual care team
huddle signaling a patientrsquos readiness
for discharge
bull Intent is to give a visual overview
DCRT
DCRT 2
bull The Anticipated
Discharge Date order
helps communicate to
the team when a
provider plan to
discharge the patient
bull The use of this order
is encouraged
DCRT 3
bull If a patient has a
high risk score of
greater than 40 a
red banner will
appear at the top
of the tool It will
NOT calculate for
PEDS Hospice or
OB patients
DCRT 4
bull DCRT displays
information already in
documented in EPIC
in a concise format
and in real time
bull Each criteria on the
report identifies
Completed items (indicated
by a red yellow or green
icon)
Incomplete items that need
to be addressed
DCRT 5
bull If care coordinators have been
identified this information will appear
bull The problem list should be reconciled
at discharge and the status will now
appear on the tool
DCRT 6
bull The Health Literacy Barriers section may
display as an FYI No action is needed
bull Click on the hyperlink to view the
Readmission Risk Report
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
Challenges
bull Concerns with not being able to view
DC instructions in EPIC
bull Medication Reconciliation not complete
bull Clinic scheduling follow-up difficulty
bull Issue with needs addressed prior to
discharge
bull Communication from physician on
discharge
Discharge Readiness Tool
(DCRT)
bull Developed as a real-time EPIC based
tool that leverages nationally published
and studiedproven tools such as
Project RED and BOOST
bull It can also simulate a virtual care team
huddle signaling a patientrsquos readiness
for discharge
bull Intent is to give a visual overview
DCRT
DCRT 2
bull The Anticipated
Discharge Date order
helps communicate to
the team when a
provider plan to
discharge the patient
bull The use of this order
is encouraged
DCRT 3
bull If a patient has a
high risk score of
greater than 40 a
red banner will
appear at the top
of the tool It will
NOT calculate for
PEDS Hospice or
OB patients
DCRT 4
bull DCRT displays
information already in
documented in EPIC
in a concise format
and in real time
bull Each criteria on the
report identifies
Completed items (indicated
by a red yellow or green
icon)
Incomplete items that need
to be addressed
DCRT 5
bull If care coordinators have been
identified this information will appear
bull The problem list should be reconciled
at discharge and the status will now
appear on the tool
DCRT 6
bull The Health Literacy Barriers section may
display as an FYI No action is needed
bull Click on the hyperlink to view the
Readmission Risk Report
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
Discharge Readiness Tool
(DCRT)
bull Developed as a real-time EPIC based
tool that leverages nationally published
and studiedproven tools such as
Project RED and BOOST
bull It can also simulate a virtual care team
huddle signaling a patientrsquos readiness
for discharge
bull Intent is to give a visual overview
DCRT
DCRT 2
bull The Anticipated
Discharge Date order
helps communicate to
the team when a
provider plan to
discharge the patient
bull The use of this order
is encouraged
DCRT 3
bull If a patient has a
high risk score of
greater than 40 a
red banner will
appear at the top
of the tool It will
NOT calculate for
PEDS Hospice or
OB patients
DCRT 4
bull DCRT displays
information already in
documented in EPIC
in a concise format
and in real time
bull Each criteria on the
report identifies
Completed items (indicated
by a red yellow or green
icon)
Incomplete items that need
to be addressed
DCRT 5
bull If care coordinators have been
identified this information will appear
bull The problem list should be reconciled
at discharge and the status will now
appear on the tool
DCRT 6
bull The Health Literacy Barriers section may
display as an FYI No action is needed
bull Click on the hyperlink to view the
Readmission Risk Report
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
DCRT
DCRT 2
bull The Anticipated
Discharge Date order
helps communicate to
the team when a
provider plan to
discharge the patient
bull The use of this order
is encouraged
DCRT 3
bull If a patient has a
high risk score of
greater than 40 a
red banner will
appear at the top
of the tool It will
NOT calculate for
PEDS Hospice or
OB patients
DCRT 4
bull DCRT displays
information already in
documented in EPIC
in a concise format
and in real time
bull Each criteria on the
report identifies
Completed items (indicated
by a red yellow or green
icon)
Incomplete items that need
to be addressed
DCRT 5
bull If care coordinators have been
identified this information will appear
bull The problem list should be reconciled
at discharge and the status will now
appear on the tool
DCRT 6
bull The Health Literacy Barriers section may
display as an FYI No action is needed
bull Click on the hyperlink to view the
Readmission Risk Report
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
DCRT 2
bull The Anticipated
Discharge Date order
helps communicate to
the team when a
provider plan to
discharge the patient
bull The use of this order
is encouraged
DCRT 3
bull If a patient has a
high risk score of
greater than 40 a
red banner will
appear at the top
of the tool It will
NOT calculate for
PEDS Hospice or
OB patients
DCRT 4
bull DCRT displays
information already in
documented in EPIC
in a concise format
and in real time
bull Each criteria on the
report identifies
Completed items (indicated
by a red yellow or green
icon)
Incomplete items that need
to be addressed
DCRT 5
bull If care coordinators have been
identified this information will appear
bull The problem list should be reconciled
at discharge and the status will now
appear on the tool
DCRT 6
bull The Health Literacy Barriers section may
display as an FYI No action is needed
bull Click on the hyperlink to view the
Readmission Risk Report
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
DCRT 3
bull If a patient has a
high risk score of
greater than 40 a
red banner will
appear at the top
of the tool It will
NOT calculate for
PEDS Hospice or
OB patients
DCRT 4
bull DCRT displays
information already in
documented in EPIC
in a concise format
and in real time
bull Each criteria on the
report identifies
Completed items (indicated
by a red yellow or green
icon)
Incomplete items that need
to be addressed
DCRT 5
bull If care coordinators have been
identified this information will appear
bull The problem list should be reconciled
at discharge and the status will now
appear on the tool
DCRT 6
bull The Health Literacy Barriers section may
display as an FYI No action is needed
bull Click on the hyperlink to view the
Readmission Risk Report
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
DCRT 4
bull DCRT displays
information already in
documented in EPIC
in a concise format
and in real time
bull Each criteria on the
report identifies
Completed items (indicated
by a red yellow or green
icon)
Incomplete items that need
to be addressed
DCRT 5
bull If care coordinators have been
identified this information will appear
bull The problem list should be reconciled
at discharge and the status will now
appear on the tool
DCRT 6
bull The Health Literacy Barriers section may
display as an FYI No action is needed
bull Click on the hyperlink to view the
Readmission Risk Report
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
DCRT 5
bull If care coordinators have been
identified this information will appear
bull The problem list should be reconciled
at discharge and the status will now
appear on the tool
DCRT 6
bull The Health Literacy Barriers section may
display as an FYI No action is needed
bull Click on the hyperlink to view the
Readmission Risk Report
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
DCRT 6
bull The Health Literacy Barriers section may
display as an FYI No action is needed
bull Click on the hyperlink to view the
Readmission Risk Report
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
DCRT 7
bull You can wrench in the DC Readiness Report by going to the right of the report field
bull The add or remove buttons from toolbar window will display
bull In the next available cell type DC R
bull Press Enter
bull The DC Readiness Report displays
bull Click accept
bull The report displays on the summary report tool bar
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
Resources for Reducing
Readmissions
1 Identify which populations are at greatest risk for readmissions elderly very sick complex needs on discharge
2 Start planning discharge at admission
3 Ensure patients schedule a 7-day follow-up with PCP
4 Ensure smooth transitional care In addition to home health transitional care has been shown to decrease number of readmissions This could feature a transitional team lead or professional who facilitates the coordination and continuity of care for patients as they change providers post-discharge
5 Clearly communicate post-discharge instructions Utilize teach-back method in addition to written instruction This is to ensure understanding from patient
6 Include patient and family in coordination of care
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
Questions
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah
References
Cleveland Clinic Health System 2017 Discharge Readiness
Tool Quick Reference Guide
httpspoccforgdepartmentsCSOTrainingShared20Docum entsDischarge_Readiness_ Toolpdf
Joint Commission Resources 2017 Project Red
httpwwwjcrinccomabout-jcrproject-red
Society of Hospital Medicine 2017 Project Boostreg Mentored Implementation Program
httpwwwhospitalmedicineorgWebQuality_InnovationSHM_Signature_ProgramsMentored_ImplementationWebQuality___InnovationMentored_ImplementationProject_BOOSTProject_BOOSTaspxgclid=CNzbq8uMvr8CFUlqfgodfL0Ah