• Randi E Berkowitz, Zachary Fang, Benjamin K I Helfand, Richard N Jones, Robert Schreiber, and Michael K Paasche-Orlow.
• Commonwealth Care Alliance, Boston, MA. Electronic address: rberkowitz@commonwealthcare.org.
• J Am Med Dir Assoc. 2013 Oct 1;14(10):736-40.

ContextPatients admitted to skilled nursing facilities (SNFs) have a high risk for rehospitalization.ObjectiveThe goal of this project was to implement Project RED in an SNF to increase patient preparedness for care transitions and lower rehospitalization rates in the 30 days after discharge from the SNF facility.DesignIntervention study with historical control; phone survey 30 days after discharge from the SNF for data collection.SettingThe study was conducted in an SNF admitting patients from acute care hospitals in Boston, MA.Patients Or Other ParticipantsA consecutive sample of patients in the SNF before (n = 524) and after initiation (n = 100) of the intervention. Participants had an average age of 80 (SD = 10), 67% were female, and 84% were non-Hispanic white. Phone surveys were completed with 88% of participants in each group.Intervention(S)We adapted Project RED for use in an SNF. This includes a comprehensive approach to transitions of care that includes creating and teaching a personalized care plan to patients and their families. Software facilitating these activities was integrated into the electronic medical record of the SNF; intervention activities were delivered by existing staff.Main Outcome Measure(S)The main outcome was hospital readmission within 30 days of discharge from the SNF. Secondary outcomes included attendance to a medical appointment within 30 days of discharge from the SNF and preparedness for care transitions as measured by a 6-item survey.ResultsThe rate of hospitalization 30 days after discharge from the SNF for participants prior to the intervention was 18.9% and for participants during the intervention was 10.2%, P < .05. This remained significant adjusting for multiple potential confounders (P = .045). More patients in the intervention group had attended an outpatient appointment within 30 days of discharge (70.5% versus 52.0%, P < .003). In addition, intervention participants reported a higher level of preparedness for care transitions.ConclusionsPatients in the intervention had a lower rate of returning to the hospital within 30 days of discharge from the SNF, were more likely to attend medical appointments, and were better prepared for their care transition.Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.

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