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Service Delivery Innovation Profile

Standardized Discharge Planning Focusing on Patient Education and Care Coordination Increases Understanding of Postdischarge Needs and Likelihood of Followup Care

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The Re-Engineered Discharge project (Project RED) at Boston Medical Center standardizes the hospital discharge process through the use of 11 separate but mutually reinforcing steps that health care professionals follow from patient admission to postdischarge. The steps incorporate the provision of patient education, care coordination with primary care physicians, and postdischarge followup with a pharmacist. The program reduced the rate of hospital readmissions and emergency department visits in the first month after discharge, improved patients’ understanding of postdischarge needs, and increased the likelihood of timely followup care.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial that assesses various measures related to patients’ preparedness for self-care, understanding of postdischarge roles and responsibilities, and the likelihood of receiving followup PCP care.
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Developing Organizations

Boston Medical Center
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Date First Implemented


Problem Addressed

The hospital discharge process is often fragmented, highly variable, and haphazard. As a result, newly discharged patients can develop complications that lead to hospital readmission. Key areas that need to be improved include patient education about diagnoses, medications, and other therapies; communication with the patient’s primary care physician (PCP) to ensure appropriate followup care; and systems for monitoring drug therapies and the patient’s overall condition after discharge.
  • Inadequate attention to discharge planning: In many hospitals, first-year residents and/or other health professionals with many competing responsibilities are charged with overseeing the discharge planning process. Their divided attention increases the risk of an incomplete and/or otherwise inadequate discharge process.1
  • Poor communication and a lack of coordination: The hospital discharge process is often characterized by poor communication and a lack of coordination between the hospital and the PCP. When patients are discharged, they often do not know what medications their physicians have prescribed, when their followup appointments should take place, and, in some cases, why they were hospitalized in the first place.2
  • Negative impact on quality: Poor discharge planning results in many patients failing to receive needed followup care from their PCP within 30 days of discharge. This lack of followup care, along with other problems caused by inadequate discharge planning, can lead to medical errors, adverse events, and high rates of rehospitalization.1

What They Did

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Description of the Innovative Activity

The Re-Engineered Discharge project (Project RED) consists of 11 mutually reinforcing steps that standardize the discharge planning process for adult, nonacute, nonsurgical patients. A nurse, acting as a discharge advocate in collaboration with the medical teams caring for the patients, follows these steps, which emphasize patient education, coordination of care, and development of a postdischarge care plan. Key elements of the project include the following:
  • Re-engineered discharge process: The revamped process consists of the following 11 steps that should be completed by the hospital staff before discharge. For Project RED, these steps were carried out by the discharge advocate. The process consists of the following steps:
    • Educate the patient about his or her diagnosis throughout the hospital stay.
    • Make appointments for clinician followup care and postdischarge testing at times and locations that are convenient and practical for the patient.
    • Discuss with the patient any tests or studies that have been completed in the hospital, and discuss who will be responsible for following up with the results.
    • Organize postdischarge services.
    • Confirm the medication plan.
    • Reconcile the discharge plan with national guidelines and clinical pathways.
    • Review the appropriate steps if a problem arises.
    • Expedite transmission of the discharge plan to clinicians accepting responsibility for the patient’s care after discharge.
    • Give the patient a user-friendly discharge plan at the time of discharge.
    • Assess the patient’s degree of understanding by asking them to explain the details of the discharge plan in their own words.
    • Provide telephone reinforcement of the discharge plan and problem-solving assistance 2 to 4 days after discharge.
  • Discharge advocate: Beginning within the first 24 hours of admission, a nurse serving as a discharge advocate spends an average of 50.1 minutes providing a number of services for the patient, which correspond to the 11 steps. These services include general patient education, medication reconciliation, communicating with hospital physicians, locating a primary care provider as needed, arranging followup appointments at convenient times for the patient, connecting patients with pharmacies, explaining discharge information, creating and explaining the postdischarge care plan, and telling patients who to contact if they have any questions or if a problem arises. In addition, information provided in April 2010 indicates that the hospital developed a virtual patient advocate position to assist in the discharge process. The virtual patient advocate educates the patient on the components of the After-Hospital Care Plan (see below) including diagnosis(es), medication instructions, and followup appointments. Following the interaction with the virtual patient advocate, the discharge advocate addresses any additional information (i.e., information on a medication not in the database) and/or provides clarification on any topic already covered.
  • After-Hospital Care Plan: The After-Hospital Care Plan is a spiral-bound, color booklet designed to clearly present the information patients need to prepare them for the days between discharge and the first visit with their PCP.
    • Discharge planning workstation: The discharge advocate enters relevant patient information into a dedicated, computerized workstation that serves as the nexus of all information regarding patient discharge and followup care. The information is then used to create a draft of the After-Hospital Care Plan. The discharge advocate asks the patient’s physician to approve the draft; once finalized, the discharge advocate prints a final copy that is spiral bound and used in patient education.
    • After-Hospital Care Plan contents: The plan contains information about the discharge diagnosis; a list of discharge medications, including why and when the patient needs to take each medication; a daily medication schedule that indicates visually what time medications should be taken; instructions about what the patient should do if his or her condition changes, including phone numbers of outpatient providers; a calendar indicating scheduled appointments with outpatient providers and/or followup tests; information on diet, exercise, and home equipment; and information to enable the patient to take an active role in followup care.
  • Outreach by pharmacists: A pharmacist calls patients 2 to 4 days after discharge to review their medications, assess whether they are taking the medications as prescribed, determine whether they understand how and when to take them, verify the dosage and times of day the patient should take the medications, explain the potential for adverse events such as drug–drug or drug–food interactions, and intervene when necessary.

Context of the Innovation

Boston Medical Center is a private, not-for-profit, 547-bed academic medical center located in downtown Boston. Boston Medical Center serves an ethnically diverse, low-income community of patients, many of whom are often readmitted to the hospital. Since 2004, the Boston Medical Center research team has used the resources of the Agency for Healthcare Research and Quality (AHRQ) Developmental Center for Patient Safety Research at Boston University-Morehouse College of Medicine to identify and address sources of error at discharge that may lead to subsequent hospital utilization. Given this information, the researchers believed that a standardized process for improving the transition from hospital to community care would improve care quality.

Did It Work?

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Final results from a randomized controlled trial of 749 patients (published in 2009) show that the revamped discharge planning process decreased the rate of hospital readmissions and emergency department visits by about one-third in the month after discharge, improved patients’ understanding of their expected roles after discharge, and increased the likelihood that patients received timely followup care.3 Results are as follows:
  • Reduced rehospitalization rate: The rate at which patients were readmitted to the hospital in the 30 days after discharge was 30 percent lower for the intervention group compared with the control group (0.314 vs. 0.451 visits per person per month). Emergency department visits were 33 percent lower in the intervention group (0.165 vs. 0.245 visits per person per month).
  • Improved patient understanding of condition and followup care needs: The revised discharge planning process enhanced patients’ understanding of postdischarge roles and responsibilities. For example, 66 percent of the intervention patients understood their primary diagnosis when they left the hospital, compared with 57 percent of the control patients, and 89 percent of intervention patients understood how to take their medications after hospital discharge, compared with 83 percent of control patients.
  • Better patient perception of preparedness for discharge: Sixty-five percent of patients receiving the intervention felt prepared to leave the hospital, compared with 55 percent of control patients. In addition, 77 percent of intervention patients believed their questions had been answered before they left the hospital, whereas only 62 percent of control patients felt that way.
  • Increased likelihood of followup care: Overall, 86 percent of the intervention patients understood what appointments they were supposed to have after leaving the hospital, compared with 79 percent of control patients. Sixty-two percent of those in the intervention group reported having seen their PCP in the 30 days after discharge, compared with 44 percent of the control group.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial that assesses various measures related to patients’ preparedness for self-care, understanding of postdischarge roles and responsibilities, and the likelihood of receiving followup PCP care.

How They Did It

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Planning and Development Process

The planning and development process included the following:
  • Upfront problem analysis: Researchers applied probabilistic risk assessment, process mapping, qualitative analyses, failure mode and effect analysis, and root cause analysis to determine the factors in the standard discharge process that contribute to high rates of rehospitalization; these analyses helped to inform the development of the re-engineered discharge planning process.
  • Development of multidisciplinary teams: The researchers assembled two multidisciplinary teams to advise the project team, conduct various aspects of the project, ensure continuity of progress and diversity of ideas, and provide oversight and hospital-wide support.
    • Advisory group: An advisory group that met monthly comprised the chief medical officer, the directors of Developmental Center for Patient Safety Research, senior researchers and statisticians, and Boston Medical Center's directors of nursing, inpatient service, case management, and quality improvement.
    • Working group: A working group that met weekly consisted of a health services researcher, statistician, substance abuse counselor, a clinical pharmacist, directors of the inpatient teams, a research assistant, a discharge advocate, and a hospital administrator.
  • Development of underlying principles: The researchers and members of the advisory groups developed a number of principles to guide the new process, including explicit delineation of roles and responsibilities; provision of patient education throughout hospitalization; expedited information flow between hospital team members and the patient’s PCP; ongoing information capture; the development of a comprehensive written discharge plan for each patient; reinforcement of the discharge plan after discharge; delivery of information to the PCP within 24 hours; readily available case management staff; and presentation of discharge information in the patient’s language and at his/her educational level.
  • Development of program components: The teams developed the 11-step process, the After-Hospital Care Plan, and the provider training manual.
  • Hiring and training of staff: Information provided in April 2009 indicates that research nurses were hired to function as discharge advocates; their only responsibility was to carry out the 11-step process with intervention patients. The provider training manual was utilized in the training of the discharge advocates. Research assistants assisted the discharge advocates in the delivery of the intervention. The research team notified the medical teams and floor nurses about the conduct of the trial.
  • Study design: Researchers designed a randomized controlled trial to test the re-engineered discharge process.

Resources Used and Skills Needed

  • Staffing: In addition to the aforementioned advisory groups, project staffing includes a principle investigator (0.2 full-time equivalents, or FTEs); data and adverse event analysts (1.5 FTEs); postdischarge re-enforcement professionals (0.125 FTEs); research assistants (2 FTEs); discharge advocates (35 hours/week); a discharge intervention director (0.125 FTEs); and a director of health literacy (0.2 FTEs).
  • Computer equipment and technical support: A dedicated discharge workstation with a computer, printer, and supplies was designated for the creation of After-Hospital Care Plans. Current work includes integrating the dedicated workstation into the hospital's electronic health record system.
  • Costs: Cost analysis data provided in April 2009 showed that the total cost of hospital utilization in the 30 days after discharge was $149,995 higher in the control group than the intervention group. This accounted for hospital readmissions and emergency department visits, as well as outpatient followup with primary care providers, which was more expensive in the intervention group (because more patients followup). The cost reduction was thus 33.9 percent, with a savings of $412 per discharge (not including the cost of the intervention).
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Funding Sources

Agency for Healthcare Research and Quality; National Heart, Lung, and Blood Institute (U.S.)
  • Project development (2004): The AHRQ Safe Practices Implementation Challenge Grant Program (HS-014289-01) provided funding for an indepth analysis and redesign of the current hospital discharge.
  • Trial (2005): The AHRQ Partnerships in Implementing Patient Safety and the National Heart, Lung, and Blood Institute of the National Institutes of Health provided funding for the randomized controlled trial.
  • Ambulatory care integration (2007): The AHRQ Ambulatory Safety and Quality provided funding for integration of Project RED into the ambulatory setting.
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Tools and Other Resources

The Project RED Web site can be accessed at: The site includes information about Project RED, a sample After-Hospital Care Plan, and a provider training manual and workbook for health professionals that describes how to safely and effectively discharge patients. The manual contains a detailed script that providers can use to collect the necessary information for discharge.

Adoption Considerations

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Getting Started with This Innovation

  • Clearly delineate staff responsibilities: Staff members should understand their roles and responsibilities related to the revised discharge planning process.
  • Implement individual components of the program if necessary: In some cases, implementing the entire 11-step process is impractical; however, implementing discrete steps can be valuable.
  • Ensure patient understanding: Consider patients’ general and health literacy levels when designing patient education materials and tools to be used after discharge; present patients with discharge information they can understand by using simple language rather than medical terminology. In addition, confirm the postdischarge care plan with patients to ensure their understanding.
  • Ensure adequate time for discharge education: Build in time to educate and explain to patients everything they need to know about their condition and required care during and after hospitalization.
  • Ensure that followup care is convenient for the patient: Make followup appointments at times that are convenient for patients, and have patients verify that they will be able to come for these visits.
  • Extend access to case management staff: Case managers should be readily available throughout the day. Efficient and safe discharge is significantly more difficult to achieve if staff work only the 7 a.m. to 3 p.m. shift.
  • Create a checklist of discharge-related tasks for staff use: Use of this tool increases the likelihood that staff members follow all necessary discharge process steps.

Sustaining This Innovation

  • Continually work to overcome ongoing challenges: Ongoing challenges may relate to ensuring patient understanding of discharge education, ensuring proper medication reconciliation, and ensuring timely followup care for patients whose PCPs have long appointment wait times.

Spreading This Innovation

Project RED has been chosen as a National Quality Forum (NQF)–Endorsed™ Safe Practice, one of 30 practices that the NQF recommends that all hospitals should adopt to be considered a “safe” organization.

More Information

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Contact the Innovator

Brian Jack, MD
Principal Investigator

Contact Person:
Jessica M. Martin, MA
Project Manager
Boston Medical Center
1 BMC Place
Dowling 5 – South
Boston, MA 02118
Phone: (617) 414-6207
Fax: (617) 414-3345

Innovator Disclosures

Dr. Jack and Ms. Martin have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178-87. [PubMed]

Greenwald JL, Denham, CR, Jack BW. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. J Patient Saf. 2007;3(2):97-106. Available at: (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Kartha A, Anthony D, Manasseh CS, et al. Depression is a risk factor for rehospitalization in medical inpatients. Prim Care Companion J Clin Psychiatry. 2007;9(4):256-62. [PubMed] Available at:

Strunin L, Stone M, Jack B. Understanding rehospitalization risk: can the hospital discharge be modified to impact recurrent hospitalization. J Hosp Med. 2007;2(5):297-304. [PubMed]


1 Anthony D, Chetty VK, Kartha A, et al. Re-engineering the hospital discharge: an example of a multifaceted process evaluation. In: Henriksen K, Battles JB, Mark ES, et al., editors. Advances in patient safety: from research to implementation. Vol. 2, Concepts and methodology. AHRQ Publication No. 05-0021-2. Rockville, MD: Agency for Healthcare Research and Quality; 2005. Available at:
2 Agency for Healthcare Research and Quality. Reengineering hospital discharge process could improve care, say AHRQ researchers. AHRQ Patient Safety E-Newsletter. August 6, 2007. Available at:
3 Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178-87. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: August 27, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 06, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.