Date of Publication


Project Team

Stuart Whitney, EdD & Barbara Quealy, MBA


Enhancing Discharge Transitions at Gifford Health Care

Megan L. O’Brien, MS, FNP-BC, APRN

Purpose. During transitions of hospital discharge, errors and lack of education pose risks to patients resulting in dissatisfaction with hospital care, poorly attended follow-up appointments, and readmissions. Discharge planning that encompasses patient centered, multidisciplinary principles have been proven to reduce health care costs while increasing satisfaction among patients and staff. At Gifford Health Care in Randolph, Vermont, hospital readmission rates were below the national average of 15.9%, but the patient satisfaction scores were lower than state and national averages. To improve discharge transitions, this project utilized the Boston University evidenced-based ReEngineered Discharge (ProjectRED) principles to develop three aims: 1) increase patient preparedness for self-management, 2) timely access to follow-up appointments, and 3) support the transition of care from discharge until primary care appointment.

Methods. This project set three objectives 1) improve the discharge instructions provided to patients and families at discharge, 2) access to follow-up appointments within 5 days of discharge, 3) enhance the transition period from discharge to follow-up appointment by creating a process for a structured telephone call with documentation. Process measures regarding follow-up appointments and phone calls were evaluated by random sampling chart audit. Outcome measures were evaluated using the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) survey to evaluate satisfaction scores. Implementation involved multi-disciplinary meetings involving staff, administration, technical support, pharmacy, quality team, and care management to revise the discharge order set and develop an electronic form for phone call documentation.

Results. This project yielded improved overall hospital rating (5.3%), earlier access to follow up (by 2 days), and reduced readmissions (1%). Despite these positive trends, a decrease in follow- up appointment attendance (3%) and lack of consistent follow-up phone calls was noted (

Conclusions. Improving discharge systems has been demonstrated to improve patient care and satisfaction. ProjectRED was originally developed in large, urban, tertiary care facilities. This project has demonstrated that similar outcomes can be achieved on a smaller scale by using a multidisciplinary team to implement selected evidenced based components. Data generated from this project can be used as a foundation to partner with the primary care teams to improve the follow up appointment process, and use the responses from the discharge follow-up phone call to develop further quality improvement projects around the discharge process. Future areas of work may include replication at additional smaller institutions.

Keywords. ProjectRED, discharge, transitions, patient satisfaction, readmissions

Document Type


Available for download on Sunday, November 04, 2018