Maintaining patient health after a hospital stay...
RARE - Reducing Avoidable Readmissions Effectively

Comprehensive Discharge Planning - Tools and Resources

Gap Analysis

Effective discharge planning is dependent on structures and processes. Implementing or enhancing a discharge planning program should start with a gap analysis to examine how your organization is currently performing. The gap analysis provides insight into the needs for improvement. Comprehensive Discharge Planning Gap Analysis (3-page Word doc)

Patient/Family Materials

Getting Ready to Go Home. Patient/Family Discharge Planning Checklist. This tool provides patients and family members with a list of questions that they should have answered and information on prior to discharge.

Next Step in Care. Supported by the United Hospital Fund, this website includes a variety of provider and caregiver resources and checklists. Patient/family materials are available in English, Spanish, Russian, and Chinese.

Patient PASS: A Transition Record. Developed as part of the Society of Hospital Medicine's Project BOOST (Better Outcomes for Older adults through Safe Transitions). (1-page PDF)

Personal Health Record - Discharge Preparation Checklist. Patient health record information including a structured checklist of critical activities a patient must be able to do to manage their care. (6-page PDF)

Taking Care of Myself: A Guide for I When Leave the Hospital. Template for a patient-focused after hospital care plan. Can be downloaded and completed electronically. Developed by the Agency for Healthcare Research and Quality (AHRQ), aligns with Project RED Checklist. Spanish version.

Your Discharge Planning Checklist. CMS developed a checklist that prompts patients and caregivers to ask questions about key discharge planning topics including their likely care needs, the options for continuing care, post-discharge care instructions, community-based resources, and more. (6-page PDF)

Provider Materials

Discharge Knowledge Assessment Tool. Tool to assess patient understanding of discharge instructions and care plan.

Patient Activation Assessment Form. Tool to assess patient understanding and capacity to follow through with discharge instructions. (1-page PDF)

Re-Engineered Discharge (RED) Toolkit. The Agency for Healthcare Research and Quality (AHRQ) Re-Engineered Discharge (RED) Toolkit can help hospitals reduce readmission rates by replicating the discharge process that resulted in 30 percent fewer hospital readmissions and emergency room visits. Developed by the Boston University Medical Center, the expanded toolkit provides guidance to implement the RED for all patients, including those with limited English proficiency and from diverse cultural backgrounds. The RED employs health literacy strategies to ensure that patients know how to how to care for themselves when they get home.

Taking Care of Myself: A Guide for I When Leave the Hospital. Template for a patient-focused after hospital care plan. Can be downloaded and completed electronically. Developed by the Agency for Healthcare Research and Quality (AHRQ), aligns with Project RED Checklist. Spanish version.

TARGET: Geriatric Evaluation for Transitions. From Project BOOST: 4-part tool that includes: Risk stratification, risk specific intervention plan, universal expectations for patient discharge to home, general assessment preparedness/readiness for transition out of the hospital.

Transitional Care Planning Model. Model for initial screening and assessment to identifying patients at moderate to high risk for readmissions. Developed by the New York State Discharge Planning Workgroup.

Models

Better Outcomes for Older Adults through Safe Transitions (BOOST). Toolkit for improving hospital discharge, including screening/assessment tools, discharge checklist, transition record, teach-back process, risk-specific interventions, and written discharge instructions.

Project RED (Re-engineered Discharge). Standardized discharge intervention; includes patient education comprehensive discharge planning and post-discharge telephone reinforcement. Developed by the Boston University Medical Center.

Key Literature

Hospitalized Patients' Understanding of Their Plan of Care. Kevin J. O'Leary, MD, MS, Nita Kulkarni, MD, Matthew P. Landler, MD, Jiyeon Jeon, MPH, Katherine J. Hahn, BS, Katherine M. Englert, and Mark V. Williams, MD.

Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Society of Hospital Medicine, 2007.

A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Jack BW, Chetty VK, Anthony D, Greenwald JL, Burniske GM, Johnson AE, Forsythe SR, O'Donnell JK, Paasche-Orlow MK, Manasseh C, Martin S, Culpepper L. A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Annals of Internal Medicine.

Safe Practices for Better Health Care: 2009 Update. Safe Practice 15: Discharge Planning Systems. National Quality Forum. 2009.

Patients and family members
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RARE is a campaign lead by the Institute for Clinical Systems Improvement, the Minnesota Hospital Association, and Stratis Health. This Web site is supported by Stratis Health, the Quality Improvement Organization for Minnesota, under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-MN