NEW BEDFORD – Southcoast Health has been working with local nursing facilities to improve the way they discharge elderly patients, with the goal of providing the education and support needed for a safe and effective return home.
The Project ReD program, or re-engineered discharge, has been underway for 18 months. In all, 14 nursing homes and 10 post-acute skilled nursing facilities took part in the grant-funded project.
The facilities that participated in the program saw hospital readmission rates drop by half, compared to the control group of nonparticipating facilities, Southcoast Health reported.
Southcoast Health engaged Healthcentric Advisors to work directly with nursing facilities, educating them on best practices in discharge planning, how to train family members in patient care and ways to ensure that family members understood what they were taught.
Following the program, nursing home staff discharge patients with a color-coded, large-font booklet that explains lab results, medications and reminders about their care. It provides a place for patients to record their weight and other information that they can bring for follow-up appointments with their primary care physician.
The practices are intended to improve health outcomes by having patients and their family members become more engaged in their care. The program is designed to promote greater communication and collaboration among clinicians, community services, patients and caregivers. Bristol Elder Services and Coastline Elderly Services, for instance, step in to coach elderly patients once they return home. The Southcoast Health Visiting Nurse Association is also involved.
“This project is a good start,” said Dr. Robert Caldas, senior vice president and chief medical officer for Southcoast Health. “We know from feedback that the staff, patients and families really benefited from the coordinated work that was done.”
Grace Dotson, executive director of clinical integrated care services for Southcoast Health, said the project “broke down silos and created relationships, which is wonderful.”
Caldas said the program demonstrates how collaboration and good communication could be expanded in health care to benefit patients, avoiding the problems that cause emergency department visits and readmissions to the hospital.
Rob Borkowski is a PBN staff writer. Email him at Borkowski@PBN.com.
