Original Project RED Toolkit

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).

After Hospital Care Plan (AHCP) Sample (PDF - 272 KB)

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.

Training Manual (PDF - 221 KB)

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.

Assistance

For more information about Project RED, please visit AHRQ’s Frequently Asked Questions website:

RED FAQ’s

If you have questions or comments, or need assistance with the Toolkit, please contact:

Jessica Martin, MA
Project Manager, Project RED
Department of Family Medicine, Boston Medical Center

Email: Jessica.martin@bmc.org

For more information on the Computerized Workstation to print the AHCP, please contact:

Engineered Care, Inc.

Email: info@engineeredcare.com or Phone: (866) 692-4271