Mass. providers sees hospital readmission rates of elderly patients fall by half through collaboration with nursing facilities

Southcoast Health, an affiliation of three partner hospitals in Mass., and nursing facilities have been working on the Project ReD (Re-Engineered Discharge) program, to improve how elderly patients are discharged to provide education and support for a safe and effective return home. The program involves 14 nursing homes and 10 post-acute skilled nursing facilities, including rehabilitation and palliative care centers. Southcoast says participating facilities have seen hospital readmission rates fall by half, compared to non-participating facilities. It worked with a vendor to educate nursing facilities on best practices in discharge planning and on how to train family members in patient care. Patients are discharged with a booklet that explains lab results, medications and reminders, with the goal of promoting greater communication and collaboration among clinicians, community services, patients and caregivers.