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Project RED Toolkit
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These tools were developed to facilitate the
Re-Engineered Hospital Discharge intervention.
After Hospital Care Plan (AHCP)
One of the principles of RED and of the NQF
Safe Practice is that all patients should leave the hospital
with a discharge plan. We call our discharge plan the “After
Hospital Care Plan” because in the course of our work
we realized that some patients are confused by the word
“discharge.” The AHCP is a spiral-bound, color
booklet that is designed to clearly present the information
needed by patients to prepare them for the days between
discharge and the first visit with their ambulatory care
physician. We worked with consultants from the Rhode Island
School of Design to help us with the graphic design. The
personalized AHCP lists medications and upcoming appointments
and tests; provides a color-coded calendar of upcoming appointments;
and is designed to help the patient prepare for his/her
upcoming appointment (patient activation).
Please contact Julie O’Donnell, Project Director at Phone (617) 414-4465 or E-mail Julie.Odonnell@bmc.org
for more information regarding the After Hospital Care Plan.
Download an AHCP Sample Here (This link will direct you to a brief form to complete prior to your download.)
Training Manual
We have prepared a 25-page training manual
and workbook for health professionals that describes in
detail how to deliver a safe and effective hospital discharge.
For each of the components of the RED, the manual contains
a detailed script describing how to collect the necessary
information. For example, the manual describes how to determine
the best time for the appointment, provides a photograph
of the primary care physician, and prompts providers to
ascertain that the patient has transportation, to give the
patient a map describing the location of the appointment,
and to tell the patient what to do if the appointment needs
to be changed. Detailed dialogue is provided for each step.
Please contact Julie O’Donnell, Project Director at Phone (617) 414-4465 or E-mail Julie.Odonnell@bmc.org for more information regarding the After Hospital Care Plan.
Download the Training Manual Here (This link will direct you to a brief form to complete prior to your download.)
Computerized Workstation to Print
the AHCP
Creation of the AHCP is now automated by means
of a Discharge Planning Workstation, a dedicated computer
workstation. The workstation is the nexus of all information
regarding patient discharge and discharge follow-up. It
is a stand-alone tool where the nurse responsible for the
discharge (the “discharge advocate”) enters
the key data into a database. Once this information is entered,
a draft AHCP is created automatically by the workstation.
The discharge nurse then reviews and refines this plan,
if necessary. Following this, the discharge nurse prints
out the draft discharge plan and takes it to the House Officer
for review and sign-off, making any revisions suggested
by the House Officer. Once the discharge plan has been finalized,
it is “published” and a spiral binding is added
at the workstation. The discharge advocate then teaches
and reviews the contained material to the patient at the
bedside. One of the objectives of the current proposal is
to integrate the workstation into the hospital’s electronic
health record (EHR) system (Centricity-Logician™ at
Boston Medical Center), exporting the information to the
patient’s ambulatory EHR and emailing it to the patient’s
PCP.
Please contact Julie O’Donnell, Project Director at Phone (617) 414-4465 or E-mail Julie.Odonnell@bmc.org for more information regarding the After Hospital Care Plan.
Assistance
If you have questions or comments,
or need assistance with the Toolkit, please contact:
Julie O’Donnell
Project Director
Boston Medical Center
1 BMC Place
Dowling 5 – South
Boston, MA 02118
Phone: (617) 414-4465
Email: Julie.Odonnell@bmc.org
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