AHRQ's RED Toolkit Leads to Lower Readmissions, Better Care Transitions in Two Texas Hospitals

Two Texas hospitals have used AHRQ's Re-Engineered Discharge (RED) toolkit to help significantly reduce hospital readmissions and as a catalyst for additional progress on efforts to improve patient care transitions when they leave the hospital. The facilities, Valley Baptist Medical Center (VBMC)-Brownsville and VBMC-Harlingen, are located in a region at the southernmost tip of Texas which has been identified as having among the highest Medicare costs and usage in the nation.

RED is a toolkit originally developed by AHRQ-funded patient safety researchers in Boston. It provides evidence-based tools to help hospitals re-engineer their patient discharge processes.

"RED really set the foundation for where we needed to go," says Robin Jones, R.N., quality management director at VBMC-Brownsville. "RED provided the best practice discharge interventions to impact our facility's financial penalty risk."

After RED was introduced, the two hospitals experienced the following:

• VBMC-Brownsville, a 280-bed community hospital, saw all-cause readmissions drop from 23.3 percent before introducing RED to 15 percent one year after the toolkit's 2010 implementation.
• The 586-bed VBMC-Harlingen's baseline 30-day readmissions rate for patients with heart failure, acute myocardial infarction, and pneumonia fell from 26 percent to 15 percent within a year of implementing the toolkit.  

Note: Brownsville measured one year after RED implementation; Harlingen measured three months after implementation.

RED interventions are focused on comprehensive discharge planning, patient education about hospital discharge, and post-discharge patient follow-up. By designating discharge advocates who help patients reconcile their medicines and schedule follow-up appointments with their primary care physicians, hospitals can reduce avoidable readmissions.

With a heightened focus in recent years on reducing hospital readmissions—nearly 20 percent of Medicare patients are readmitted to the hospital within 30 days of discharge—and then-looming Medicare payment reductions for hospitals with readmissions for heart attack, heart failure, and pneumonia that exceeded an established national average, VBMC-Brownsville looked to RED in 2009 to provide better discipline around its fragmented patient discharge process.

"We chose to implement RED to standardize our discharge process to a nationally recognized evidenced-based practice," Ms. Jones notes. Her team began educating inpatients about their diagnosis, confirming the medication plan with patients, educating nurses and staff on unit- and hospital-based readmission numbers, and appointing staff to make follow-up physician appointments for patients being discharged.

"We worked with our local doctors' office managers on expediting post-hospitalization follow-up appointments for our patients," Ms. Jones says. After implementing an initial pilot on the telemetry floor for heart patients in 2009, the hospital expanded RED to all telemetry floor patients before expanding it hospital-wide by the fall of 2010.

At VBMC-Harlingen, RED was introduced in September 2010, after its success at its affiliated hospital in Brownsville. With Medicare's readmission penalties set to begin in 2012, hospital officials "knew they were at risk for upcoming readmission penalties," says Angela Blackford, R.N., VBMC's system director of care management. By instituting many of the same practices that Brownsville did, VBMC-Harlingen has been able to lower the impact of Medicare's readmission penalties by 77 percent, avoiding nearly $600,000 in penalties between 2012 and 2013. (VBMC-Brownsville's relative improvement regarding readmission penalties was 71 percent for the same period.)

"RED continues today," Ms. Blackford says. "We're still doing the appointments and follow-up calls, with 95 percent of patients having [follow-up doctors'] appointments within seven days. We know RED has had a huge impact."

Both VBHS facilities have also done more to improve patient discharge and care transitions, including educating certain skilled nursing providers in the community about readmissions and participating in the Centers for Medicare and Medicaid Services' Community-based Care Transitions Program. Between RED and other efforts, the two hospitals have reduced readmissions from a combined 28 percent in fiscal year 2011 to 21 percent in fiscal year 2012 to 13.7 percent in fiscal year 2013.