Southcoast Health leads collaboration to transition elderly patients home

Southcoast Health has been working with area nursing facilities to improve the way they discharge elderly patients, with the goal of providing the education and support needed for a safe and effective return home.

The so-called Project ReD program, which stands for re-engineered discharge, has been underway for 18 months. In all, 14 nursing homes and 10 post-acute skilled nursing facilities, such as rehabilitation and palliative care centers, took part in the grant-funded project.

The facilities that participated in the program saw hospital readmission rates drop by half, compared to the control group of non-participating facilities, Southcoast Health reported.

Southcoast Health engaged Healthcentric Advisors to work directly with nursing facilities, educating them on best practices in discharge planning, how to train family members in patient care and ways to ensure that family members understood what they were taught.

Patients are discharged with a color-coded, large-font booklet that explains lab results, medications and reminders. It provides a place for patients to record their weight and other information that they then can bring for follow up with their primary care physician.

The idea is to improve outcomes by having patients, along with their family members, more confident and engaged in their care. It promotes greater communication and collaboration among clinicians, community services, patients and caregivers. Bristol Elder Services and Coastline Elderly Services, for instance, step in to coach elderly patients once they return home. The Southcoast Health Visiting Nurse Association also are involved.

“This project is a good start,” said Dr. Robert Caldas, Senior Vice President & Chief Medical Officer for Southcoast Health. “We know from feedback that the staff, patients and families really benefited from the coordinated work that was done.”

Grace Dotson, Executive Director of Clinical Integrated Care Services for Southcoast Health, said that the project “broke down silos and created relationships, which is wonderful.”

Dr. Caldas said the program demonstrates how collaboration and good communication could be expanded in healthcare to benefit patients, avoiding the problems that cause emergency department visits and readmissions to the hospital.