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.
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