• TS: – Achieve Success in Reducing Hospital Readmissions: Dedicated Discharge Staff Can Make the Difference[®] [PEARL: RN] The Source, April 2013, Vol 11, #4, Pg 13

A significant portion of patients requiring readmission do so because of difficulty in managing their transition into the next phase/level of care.  Partly for this reason, this article shares the success of a university medical center in effecting Re-Engineered Discharge (RED) Interventions through the use of a specially trained nurse as a dedicated discharge advocate.  While the discharge function in our facilities is most often in the purview of Social Work, research-tested discharge Interventions such as RED (an initiative of the Hospital Engagement Network) and 3 others (i.e., Transitional Care Model, Care Transition Program and Evercare) briefly summarized on page 14 of this article, are worth knowing about and possibly adapting to some extent.
PEARL:  Go to Innovative Care Models, to check out profiles on 24 successful care delivery models including 3 of those mentioned here.
Note: The Hospital Engagement Network is a CMS funded project led by the Health Research & Educational Trust (HRET) and the American Hospital Association (AHA).  The 37 participating facilities do not include any State Psychiatric Hospitals.