Penn Medicine Chester County Hospital Implements AHRQ Toolkit to Reduce Readmissions

Penn Medicine Chester County Hospital, a 257-bed complex in West Chester, Pennsylvania, part of the University of Pennsylvania Health System, was one of 10 hospitals involved in AHRQ's 2011 rollout of the Re-Engineered Discharge (RED) toolkit. Initially implemented in one unit, the program is now used hospital-wide with a notable positive impact on the patient experience.

Developed by AHRQ-funded patient safety researchers in Boston, RED provides evidence-based tools to help hospitals re-engineer their patient discharge processes. This enables patients to manage their conditions at home, possibly avoiding a readmission to the hospital for the same condition.

"We initially implemented RED for congestive heart failure patients on our telemetry unit," said Carli Meister, M.Sc.A., R.N., director, customer relations and risk. "We found RED to be extraordinarily successful. Without adding additional nursing resources, we achieved a 50 percent reduction in the readmission of these patients discharged to home."  

"For us, RED's After Hospital Care Plan is the heart and soul of RED; it individualizes the standardized checklist for every discharge," Ms. Meister continued. RED's After Hospital Care Plan is a user-friendly guide that covers patients' hospital discharge through the first visit with their primary care physician.

"We hear of our patients showing up at the pharmacy holding their After Hospital Care Plan, and bringing it to community meetings and their doctor's offices. They tell us, 'I never let this out of my sight now,' and their physicians love it," commented Ms. Meister.

Based on the success with congestive heart failure patients—the notable reduction in readmissions and the enthusiasm for the After Hospital Care Plan—hospital leaders expanded the use of RED throughout the facility in 2012. Since RED's hospital-wide implementation, the average readmission rate for congestive heart failure is now between 14 and 16 percent, which is significantly lower than the national average. The readmission rate for chronic obstructive pulmonary disease also dropped, from 19 to 11.7 percent.

In implementing RED throughout the facility, the hospital incorporated several of the RED toolkit elements it found most useful. These included planning for discharge from the day of admission, teach-back, making follow-up appointments, follow-up phone calls for patients at high-risk for readmission, and—most importantly—the creation of an electronic version of the After Hospital Care Plan.

"The electronic version, 'My Discharge Plan,' was a beautifully recreated discharge plan modeled after RED's After Hospital Care Plan. It incorporates health literacy principles and is user-friendly for both patients going home and those transitioning to post-acute care facilities," Ms. Meister said.

The hospital also noted improvements in its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS^®) data that address questions about hospital discharge. These scores improved significantly due to the implementation of "My Discharge Plan."

Ms. Meister has given statewide and nationwide presentations highlighting the hospital's success and achievements using the tool to improve its discharge process. "Patients are still overwhelmed at discharge, but compared to how things were before RED, we see a huge improvement," she noted.