Project RED reduces rehospitalization rates

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Patient care

Project RED reduces rehospitalization rates

After reading this article, you will be able to:

  • Identify the reasons behind Project RED
  • Discuss the components of Project RED
  • Explain the role of a virtual discharge advocate


Patient discharge usually takes a backseat to -other quality and patient safety measures that focus on keeping patients safe in the hospital, not when they go home. However, a new trial study’s results help prove that overlooking healthy patients leaving the hospital may be costly and unsafe.

After more than five years and $7.5 million in federal funding from the Agency for Health Research and Quality, researchers of Project Re-Engineered -Hospital Discharge (Project RED) have found that a thorough and well-implemented discharge plan can reduce subsequent hospital visits by 30% and decrease cost per patient by $412.

Breaking barriers to better discharge

Brian Jack, MD, associate professor and vice chair of the department of family medicine at Boston University School of Medicine and Project RED’s principal investigator, understands the challenge of getting staff members to focus on discharge.

“The nurses, physicians, and interns are justifiably more concerned with the sick patients coming up from the [emergency room] since the people going home are the people who are relatively healthy,” says Jack. “Frankly, it’s never been a priority for hospitals to do much with them as they go home … Only now are people beginning to pay attention to the really important opportunity to be sure that people who are going home from the hospital are able to take care of themselves until that first follow-up doctor’s appointment, where they can get more advice on what to do.”

Project RED proves the effort to do more during discharge is worthwhile. Through process mapping, Failure Modes and Effects Analysis, risk assessment, and root-cause analysis, project researchers identified common problems with discharge procedures and created a list of components that were endorsed by the National Quality Forum as the basis of its Safe Practice on discharge. (See “Components of Project RED” on p. 4.)

Project RED took about 750 patients at Boston Medical Center (BMC), an urban academic center, and split them into two groups—one that would receive care as usual, and one in which care would be defined by the new principles of Project RED. The latter group of patients had its own discharge advocate who would collect all discharge information. The advocate then entered the information in software designed to create an After Hospital Care Plan (AHCP), a spiral-bound color booklet. (Jack notes that not everyone is familiar with the term “discharge,” and it was decided to name the booklet differently for patients.)

The individualized booklet is more than a simple discharge summary and contains color-coded calendars for appointment scheduling—including, if needed, how to get to each appointment. It also lists brand-name and generic medications and other information such as what time of day to take the medication (with graphics), what the pill looks like (with pictures), dosage of each medicine, how to take the medicine, and the reason for each medication. The patient discharge advocate reviews the booklet with each patient.

The results have been encouraging. Thirty days after their discharge, patients were asked how prepared they were to go home. Overall, those who were a part of Project RED felt more prepared. One readmission for ED visits was prevented for every 7.3 subjects. These are important figures, considering that CMS has begun asking for public comment on the idea of changing the -payment system for patients readmitted to the hospital. Project RED requires staff members to develop a thorough AHCP, educate patients and assess understanding, and schedule follow-up appointments with their primary care physicians.

Using virtual discharge advocates

Leaders of Project RED found that nurses, on average, spend about eight minutes with the patient at discharge. Because Project RED involves a patient discharge advocate who takes time to collect information and review the AHCP, Jack and fellow researchers looked for a way to minimize the time needed by hospital nurses to deliver the RED principles. They found it by using a health information technology (HIT) system.

Enter Louise™, a computerized hospital bedside patient education system. She helps patients through their AHCP booklet. She chitchats, goes over patients’ individualized discharge care plans, asks how they are feeling, is sympathetic, and has enough patience to repeat any piece of information patients need repeated, no matter how many times.

Patients see Louise, a computer-animated virtual nurse, on a touchscreen computer at the bedside. -Louise goes over the discharge information, asking questions along the way to ensure that patients are actively participating and understanding.

Patients are then given a list of possible answers from which to choose. The idea of the Louise system is to take the information entered into the software and use it to create the AHCP booklet and an individualized virtual education. Currently, BMC is working to integrate the hospital’s HIT system, automatically using any information already inputted into the system. This step would help eliminate more work for nurses, says Jack.

Louise is quite popular. When asked whether they would prefer a doctor, nurse, or Louise to give them their discharge instructions, 74% of patients in a pilot study preferred Louise, often saying that they enjoyed being able to sit as long as they wanted with Louise, instead of with nurses or doctors who are usually too busy to thoroughly answer their questions. Louise also mimics human facial expressions and other nonverbal behaviors that indicate sympathy and other emotions.

Although discharge improvement is still in its infancy, Jack believes that reimbursement will some day be tied to readmission rates and discharge will be a key factor of most hospital quality improvement plans. For now, though, Jack points out that rehospitalization reductions still improve quality and cut costs. Visit for more information about Project Red.


Adapted from Briefings on Patient Safety, June 2009, HCPro, Inc.

Components of Project RED

The following components make up Project Red:

  • Educate the patient about diagnosis throughout the hospital stay
  • Make appointments for follow-up and postdischarge testing, with input from the patient about the time and date
  • Discuss with the patient any tests not completed in the hospital
  • Organize postdischarge services
  • Confirm the medication plan
  • Reconcile the discharge plan with national guidelines and critical pathways
  • Review with the patient appropriate steps to take should a problem arise
  • Expedite transmission of the discharge summary to -clinicians accepting care of the patient
  • Assess the patient’s understanding of this plan
  • Give the patient a written discharge plan
  • Call the patient two to three days after discharge to reinforce the discharge plan and help with problem solving

Source: Project RED and Boston University School of Medicine. Reprinted with permission.