Managing Readmissions

Find statistics, mental-health–specific interventions, and management strategies that may help reduce readmissions and optimize the transition of care among psychiatric patients.

IDEAL Discharge Planning Implementation Handbook

"The goal of the IDEAL Discharge Planning strategy is to engage patients and family members in the transition from hospital to home, with the goal of reducing adverse events and preventable readmissions."

When IDEAL Discharge Planning was implemented in a surgical unit as part of a year-long pilot project, Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey scores trended upward for the 12-month period following implementation, particularly for measures related to discharge and communication with doctors. Hospital leaders viewed the improvements as extremely significant.

The IDEAL Discharge Planning strategy highlights the following elements of discharge planning:

Include the patient and family as full partners in the discharge planning process. 

Discuss with the patient and family five key areas to prevent problems at home:

  1. Describe what life at home will be like
  2. Review medications
  3. Highlight warning signs and problems
  4. Explain test results
  5. Make follow-up appointments

Educate the patient and family in plain language about the patient’s condition, the discharge process, and next steps at every opportunity throughout the hospital stay.

Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the patient’s care to the patient and family, and use teach-back.

Listen to and honor the patient and family’s goals, preferences, observations, and concerns.

The IDEAL Discharge Planning process should also include at least one Planning Discharge Meeting to discuss concerns and questions with the patient, family, and selected members of the discharge team.

 

Tools for the IDEAL Discharge Planning Strategy

Re-Engineered Discharge (RED) Toolkit

Help ensure a smooth and effective transition at discharge

“The Re-Engineered Discharge (RED) consists of a set of 12 mutually reinforcing actions that the hospital undertakes during and after the hospital stay to ensure a smooth and effective transition at discharge."1

 

A randomized trial using a re-engineered hospital discharge program tested the effects of an intervention designed to minimize hospital utilization after discharge. This study of 749 adults admitted to a large, urban hospital in the United States where patients were randomized to an intervention designed to minimize hospital utilization after discharge or usual care. The primary outcome of the study was the number of emergency department visits and hospitalizations within 30 days of discharge. Participants in the intervention group had a lower rate of hospital utilization than those receiving usual care (0.314 vs 0.451 visits per patient per month; P=0.009).2

Components of the RED Toolkit include:1

  1. Ascertain need for and obtain language assistance.
  2. Make appointments for follow-up care (eg, medical appointments, post-discharge tests/labs).
  3. Plan for the follow-up of results from tests or labs that are pending at discharge.
  4. Organize post-discharge outpatient services and medical equipment.
  5. Identify the correct medicines and a plan for the patient to obtain them.
  6. Reconcile the discharge plan with national guidelines.
  7. Teach a written discharge plan the patient can understand.
  8. Educate the patient about his or her diagnosis and medicines.
  9. Review with the patients what to do if a problem arises.
  10. Assess the degree of the patient’s understanding of the discharge plan.
  11. Expedite transmission of the discharge summary to clinicians accepting care of the patient.
  12. Provide telephone reinforcement of the discharge plan.

References:

  1. Re-Engineered Discharge (RED) Toolkit. April 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/red/toolkit/index.html. Accessed on June 30, 2016.
  2. Jack BW, Chetty VK, Anthony D, et al. A re-engineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):179-197.

Tools for the RED Discharge Planning Strategy


Re-Engineered Discharge (RED) Toolkit. Content last reviewed April 2016. Agency for Healthcare Research and Quality, Rockville, MD.

Guide to Patient and Family Engagement in Hospital Quality and Safety, ' Strategy 4: Care Transitions from Hospital to Home: IDEAL Discharge Planning.' Agency for Healthcare Research and Quality, Rockville, MD.