James M. Berklan
James M. Berklan

Relationships between hospitals and nursing homes can be funny things. Working together, they can do great things. But “cooperation” and “outreach” are not operative words frequently enough.

Even though a parent-figure (or Uncle Sam) might continually coax these entities to get along and do good things for other people, the reality is sibling rivalry always bubbles just under the surface.

Take their opposing views on the observation-stay quagmire, for example. Or any number of big bucks lobbying battles where acute care and long-term care interests have locked horns. Some have raged for years.

But in this era of accountable care organizations, readmissions penalties and bundled pay schemes, it’s going to be in everybody’s best interest to play nicer together. And share resources.

One such resource is Project RED (Re-Engineered Discharge), a tool currently used mostly by hospitals. It includes guidance on how professionals can work better with family caregivers for discharge and transition periods.

The research group at Boston Medical Center/Boston University School of Medicine that created Project RED, and staff from the United Hospital Fund, jointly developed the new capabilities. The project is endorsed by the National Quality Forum and the recipient of the 2013 Peter F. Drucker Award for Nonprofit Innovation,

Researchers structured how to work with family members into five stages:

1)   Identifying the family caregiver

2)    Assessing the family caregiver’s needs

3)    Integrating the family caregiver’s needs into the after-hospital care plan

4)    Sharing family caregiver information with the next setting of care

5)    Providing telephone reinforcement of the discharge plan

This has been geared toward hospital patients and their family members, but there’s no reason long-term care providers can’t adopt similar principles and practices. With so many short-stay and rehab residents, providers have many instances when a smoother hand-off to family members could improve outcomes. And reduce the likelihood of hospital readmissions, which have become everybody’s business.

Actually, Project RED already has been employed successfully in long-term care. A study recently published in the Journal of the American Medical Directors Association showed lowering of 30-day hospital readmissions of patients discharged from a skilled nursing facility.

“Our new tool will make the overall toolkit even more powerful, for hospital and long-term care workers alike,” notes Carol Levine, director of the Families and Health Care Project at United Hospital Fund, and an author of the new tool. It is the first addition to the toolkit since its launch in 2007.  

The tool fills a gap that creators “didn’t realize existed” when they first developed Project RED, says Brian Jack, MD, professor and chair of the Department of Family Medicine at Boston University School of Medicine/Boston Medical Center. He’s also principal investigator of Project RED, and another of its authors.

A systematic approach that gets family members more involved in transition teams is a smart way to go — for hospitals and long-term care providers alike.

More than 500 hospitals — in 49 states and nine countries — have downloaded the Project RED toolkit and nurse training manual, officials say. It’s a project that little brother Long-Term Care would be wise to start downloading more himself.

The Project RED toolkit is free of charge and can be found here.


James M. Berklan is McKnight’s Editor. Follow him @LTCEditorsDesk.