Journal of the American Medical Directors Association
Original StudyProject ReEngineered Discharge (RED) Lowers Hospital Readmissions of Patients Discharged From a Skilled Nursing Facility
Section snippets
Methods
Project RED was adapted for implementation at an SNF by a planning committee composed of a patient who had been discharged from the unit, floor nurses, the medical director of the SNF (R.E.B.), the license administrator for the SNF, the director of nursing, a staff therapist, a dietician, and both social work case managers. The committee sought input from a range of stakeholders, including patient family members, home care nurses and administrators, clergy, and experts in interventions for care
Results
There were 524 participants in the control period and 100 participants in the intervention period; in both groups, 88% were successfully surveyed by phone. Participants had an average age of 80 (SD = 10), 67% were female, and 84% were non-Hispanic white (Table 2). Participants in the intervention period did not differ with respect to age, diabetes, heart failure, or pneumonia with those before the intervention. The rate of chronic lung disease was higher before the intervention and this group
Discussion
Project RED was successfully adapted and implemented in an SNF and lowered the rate of hospitalization within 30 days of discharge from the SNF from 18.9% to 10.2%. Patients reported seeing their outpatient providers more frequently within 30 days of discharge from the SNF. Patients also reported a higher level of preparedness for discharge. This intervention was implemented with existing SNF staff and resulted in a 46% reduction in the number of people being readmitted within 30 days. The
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R.E.B. is the primary investigator and had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. R.E.B., R.S., R.N.J., Z.F., and B.K.I.H. report no financial disclosures or conflicts of interest. The Hebrew SeniorLife Physician-in-Chief fund supported the time of the staff for this improvement project.
M.K.P.-O. serves as a consultant to Engineered Care, Inc, the exclusive licensee from Boston University of Project RED.