AHRQ’s RED Toolkit Helps VA Hospitals in California and Texas Lower Readmissions, Improve Discharge Process

Thirty-day all-cause hospital readmissions at the Department of Veterans Affairs (VA) Palo Alto (CA) Health Care System dropped 30 percent after administrators and clinicians implemented AHRQ's Re-Engineered Discharge (RED) Toolkit. Readmission rates fell to less than 9 percent after ranging between 14 and 16 percent before the toolkit was adopted.

"I just can't express how much RED helped our facility," said David Renfro, R.N., chief of nursing, specialty, and hospital-based services at VA Palo Alto. The facility, which already had readmission rates below the national average, began implementing RED in June 2012. They had help from Brian Jack, M.D., the Boston University Medical Center researcher funded by AHRQ to develop RED, and Engineered Care, a San Francisco-based health care company that has exclusively licensed RED for commercial dissemination.

The RED toolkit provides guidance to hospitals on comprehensive discharge planning and helps patients prepare for life at home after a hospital stay. Elements include arranging for follow-up care from a primary care physician or specialist, helping patients anticipate and understand pending lab results, explaining new medications, and follow-up calls to patients to reinforce discharge plans. Discharge advocates are designated to support hospital efforts to reduce avoidable readmissions. The Palo Alto site implemented all elements of RED with grant support from the Gordon and Betty Moore Foundation.

"It was all or nothing," said Mr. Renfro about implementing RED. "We assigned a champion to each element," adding that teams met regularly about the implementation and to learn from one another.

While all the elements are important, Mr. Renfro said medication reconciliation, the teach-back method, and the follow-up phone calls to patients within 24 to 48 hours of discharge are "critical" components. Progress has been made, but the facility has a "stretch goal" of getting readmissions down to 8.8 percent.

Engineered Care worked with the VA's Office of Information and Technology to create a personalized template based on AHRQ's "Taking Care of Myself" brochure. The After Hospital Care Plan booklet—a component of RED that provides discharged patients with the reason for their hospitalization, medication information, instructions about their conditions, coordinating information, and more—can be populated in a large part by the VA's electronic medical record system, called VistA. For nearly two years, the VA Palo Alto staff completed the After Hospital Care Plan by hand. Automating that process has significantly streamlined the discharge process.

Meanwhile, the Michael E. DeBakey VA Medical Center in Houston also began automating the After Hospital Care Plan. In late 2013, the Houston VA's Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) began adapting RED to address post-surgical discharges. In summer of 2014, they partnered with the operative care leadership and staff at the DeBakey VA Medical Center to begin implementing RED for patients discharged following abdominal surgery. The efforts include integrating the VA electronic medical records system with the After Hospital Care Plan.

"There have been notable improvements in the discharge process over the first six months of implementation," said Aanand Naik, M.D., a clinician-investigator at IQuESt. "We experienced a 35 percent increase in monthly pharmacist-led medication reconciliations prior to discharge that are incorporated into the After Hospital Care Plan. About half of all discharges on the target wards received the full RED intervention during the first six months."