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