1. Project RED The Re-Engineered Discharge JCR’s AHRQ-funded Project August 2010 Deborah Nadzam Susan Whitehurst

2. Project RED Checklist Eleven mutually reinforcing components: 1. Medication reconciliation 2. Reconcile discharge plan with national guidelines 3. Follow-up appointments 4. Outstanding tests 5. Post-discharge services 6. Written discharge plan 7. What to do if problem arises 8. Patient education 9. Assess patient understanding 10. Discharge summary sent to PCP 11.Telephone reinforcement Adopted by National Quality Forum as one of 30 US "Safe Practices" (SP-15)

3. 11 RED Components Enable Discharge Advocates to: Prepare patients for hospital discharge Help patients safely transition from hospital to home Promote patient self-health management Support patients after discharge through follow-up phone call

4. Project Expectations Secure executive sponsorship Assign project team and project leader Identify targeted population of patients* Determine approach for generating After Hospital Care Plan (ACHP)* Identify discharge advocate(s) and staff to make post-discharge phone calls Participate in focus group conference call

5. Project Expectations cont’d Participate in training Schedule bi-weekly consulting calls with assigned JCR consultant Provide data to JCR re: readmission, ALOS Participate in all-site web conference discussions Participate in case-study interviews

6. Current Status 30 participants – Proceeding with training and implementing 20 more expected to enroll Possible additional AHRQ funding to support 75 more hospitals

7. Project RED Training Course designed and available to participants via JCR’s BlackBoard Recorded webinars, with homework! – Module 1 – Designing a strong PI program – Module 2 – Operationalizing Project RED (A) – Module 3 – Operationalizing Project RED (B) Live Module 4 – content and open discussion Several handouts and tools

13. After Hospital Care Plan

14. Ready for Project RED? Next Steps – Secure leadership commitment – Identify targeted populations to begin – Determine approach for developing After Hospital Care Plan – Identify staff: Project Leader, Project Team, Discharge Advocate(s)

15. Identify Targeted Patient Population Start small! Approaches to consider – Specific patient care unit – Diagnostic group – Physician’s patient group – Combination of above Also – English-speaking patients – Discharged home – Access to telephone

16. Developing the Patient’s Care Plan Accessing the care plan template Accessing information for the care plan Saving individual patient’s care plan Printing the care plan Storing the care plan – Permanent part of the patient record? Care Plan Development

17. Generating the AHCP “Manual” – use of template for discharge advocate (DA) to enter all required data www.ahrq.gov/qual/goinghomeguide.htm Provide template to your IT department and request that they integrate with existing systems Purchase software and integrate it with your existing systems

18. To participate in JCR’s AHRQ-funded project focused on Project RED Contact Deborah Nadzam dnadzam@jcrinc.com 630-261-5048