Adapting Project RED to Skilled Nursing Facilities.

Area of Science:

• Healthcare Management
• Patient Care Transitions
• Quality Improvement

Background:

• Hospital-based Reengineered Discharge (RED) programs aim to reduce readmissions and improve patient outcomes.
• Skilled nursing facilities (SNFs) play a crucial role in post-hospital care, but often face challenges in discharge processes.
• Adapting successful hospital discharge interventions to the SNF setting is essential for seamless patient care.

Purpose of the Study:

• To recommend adaptations of the hospital-based Reengineered Discharge (RED) process for implementation in skilled nursing facilities (SNFs).
• To identify key components of RED that can be effectively integrated into SNF discharge protocols.
• To address barriers and facilitators for adopting RED processes within SNFs.

Main Methods:

• Focus groups were conducted with SNF staff to assess existing discharge processes.
• Research staff collected field notes documenting discussions on RED process alignment with SNF practices.
• Thematic analysis was used to systematically analyze qualitative data and derive recommendations.

Main Results:

• Key recommendations for SNF adaptation include: rapid identification and preparation of family/caregivers for patient-centered discharge plans.
• Facilitating prompt reconnection of patients with their primary care providers.
• Enhancing patient education at discharge regarding health conditions, medications, and impact on other chronic needs.
• Identified limitations to adoption included SNF staff capacity and corporate policies.

Conclusions:

• The Reengineered Discharge (RED) process, a transitional care model, can be successfully adapted for SNFs to enhance discharge effectiveness.
• Adapting RED principles can mitigate common discharge problems and improve the quality of care transitions from SNFs.
• Addressing resource limitations and policy constraints is crucial for successful implementation of adapted RED processes in SNFs.