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Three California hospitals are among those in the San Francisco-based Dignity Health system using AHRQ's Re-Engineered Discharge (RED) Toolkit to reduce hospital readmissions and improve care transitions.

"The RED Toolkit has been very useful, user friendly, and effective," said Michael Smith, R.N., supervisor of readmissions and discharge planning at the 426-bed Bakersfield Memorial Hospital. The hospital cut its 30-day Medicare readmission rate by more than half within months of implementing elements in the RED Toolkit. "RED provided the necessary evidence-based framework to help us develop a more comprehensive and appropriate discharge planning and care transitions process," Mr. Smith continued.

Bakersfield Memorial and two sister hospitals have documented significant reductions in readmissions since implementing RED:

• Bakersfield Memorial saw 30-day readmissions for Medicare patients drop over a 6-month period that ended June 2014 to 11.3 percent from 25 percent, based on a similar period that ended in late 2013; all-payer 30-day readmissions dropped to 6.5 percent between January and July 2014 from an average of 7.5 percent in 2013.
• St. Mary’s Medical Center, a 389-bed trauma center in Long Beach, introduced RED in December 2013 for heart failure patients and saw readmissions for this population drop to 7.7 percent as of July 2014 from 22.2 percent in November 2013, helping to reduce all-cause readmissions to 5.7 percent.
• San Francisco’s 300-bed St. Mary’s Medical Center also introduced RED with heart failure patients, which helped the facility reduce the hospital’s overall readmissions rate by more than 20 percent, to 5.5 percent in June 2014 from 7.6 percent in January 2013.

These facilities are among several of Dignity Health's 31 California hospitals using RED. The system oversees a readmission strategy for its hospitals, setting targets for each institution. The system's all-cause target for fiscal year 2015 is 6.8 percent, according to Zenobia Collins Johnson, R.N., B.S.N., M.B.A., project director of readmissions reduction with Dignity Health Care Management.

"Our mission is to deliver compassionate, high-quality, affordable health care to our communities," said Ms. Collins Johnson. "Implementing RED and the resulting reduced readmissions is a significant and important part of that work."

RED, developed by AHRQ-funded researchers, provides evidence-based tools to help hospitals re-engineer their patient discharge processes. RED interventions focus on comprehensive discharge planning, patient education, and post-discharge patient follow-up. By designating discharge advocates who help patients reconcile their medicines and schedule follow-up appointments with their physicians, hospitals can reduce avoidable readmissions.

Bakersfield Memorial implemented most of RED's elements on its adult floors. Mr. Smith added, "The most helpful was scheduling patient appointments with providers prior to discharge, as well as creating our Discharge Call Program. Patients who are discharged home receive a follow-up phone call within 72 hours" as well as three additional calls within 31 days of discharge.

After seeing the success of the RED Toolkit in reducing readmissions among heart failure patients, officials at the Long Beach hospital expanded RED to patients with chronic obstructive pulmonary disease, pneumonia, and sepsis. "We want to identify the high-risk patients—those who need extra resources before discharging them to the community—and reduce readmissions," said Ardel Avelino, R.N., M.H.A., P.H.N., associate administrator.

For hospital officials, the most helpful aspects of the RED Toolkit have been the teach-back method for educating inpatients about their diagnosis and appointing a nurse practitioner and health coach to oversee the discharge team. This team prompts other team members to educate patients, help them manage medications, set up doctors' appointments, and contact patients after discharge. "RED produces high-quality outcomes," said Mr. Avelino. "If you adhere to it consistently, it works."

St. Mary's Medical Center in San Francisco implemented RED in 2012. The hospital instituted teach-back, follow-up appointments, patient call-backs, and other aspects of RED. After seeing initial success with heart failure patients, the hospital instituted nearly all RED Toolkit elements hospital-wide beginning in January 2014.