Re-Engineered Discharge (RED) Toolkit

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Patient name:

Caregiver(s) name(s):

Relationship to patient:

Notes:

Discharge date:

Principal discharge diagnosis:

Interpreter needed? Y N Language/Dialect:

Prior to phone call:

Review:

• Health history.
• Medicine lists for consistency.
• Medicine list for appropriate dosing, drug-drug and drug-food interactions, and major side effects.
• Contact sheet.
• DE notes.
• Discharge summary and AHCP.

Call Completed: Y N

With whom (patient, caregiver, both): _______________________________________________
Number of hours between discharge and phone call: ___________________________________

Consultations (if any) made prior to phone call:

___  None
___ Called MD
___ Called DE
___ Called outpatient pharmacy
___ Other: __________________________________________________________________

If any consultations, note to whom you spoke, regarding what, and with what outcome:

_______________________________________________________________________

_______________________________________________________________________

Phone Call Attempts

Patient/Proxy

Alternate Contact 1

Alternate Contact 2

A. Diagnosis and Health Status

• Ask patient about his or her diagnosis and comorbidities:

  ___ Patient confirmed understanding
  ___ Further instruction was needed

• If primary condition has worsened: What, if any, actions had the patient taken?
  ___ Returned to see his/her clinician (name):_____________________________________
  ___ Called/contacted his/her clinician (name):____________________________________
  ___ Gone to the ER/urgent care (specify):_______________________________________
  ___ Gone to another hospital/MD (name):_______________________________________
  ___ Spoken with visiting nurse (name):_________________________________________
  ___ Other:_______________________________________________________________
  ___ What, if any, recommendations, teaching, or interventions did you provide?
• 
   
• If new problem since discharge:
  • Had the patient:

       ___ Contacted or seen clinician? (name):________________________________________
       ___ Gone to the ER/urgent care? (specify):______________________________________
       ___ Gone to another hospital/MD? (name):______________________________________
       ___ Spoken with visiting nurse? (name):________________________________________
       ___ Other?:_______________________________________________________________

• Following the conversation about the current state of the patient's medical status:
  • What recommendations did you make?

       ___ Advised to call clinician (name):___________________________________________
       ___ Advised to go to the ED
       ___ Advised to call DE (name):_______________________________________________
       ___ Advised to call specialist physician (name):__________________________________
       ___ Other:_______________________________________________________________

  • What followup actions did you take?
       ___ Called clinician and called patient/caregiver back
       ___ Called DE and called patient/caregiver back
       Other: ___________________________

B. Medicines

• Document any medicines patient is taking that are NOT on AHCP and discharge summary: ___________________________________________________________________________
• Document problems with medicines that are on the AHCP and discharge summary (e.g., has not obtained, is not taking correctly, has concerns, including side effects):

  Medicine 1:_________________________________________________________________

  P roblem:___________________________________________________________________
  ___ Intentional nonadherence
  ___ Inadvertent nonadherence
  ___ System/provider error
  • What recommendation did you make to the patient/caregiver?
    ___ No change needed in discharge plan as it relates to the drug therapy
    ___ Educated patient/caregiver on proper administration, what to do about side effects, etc.
    ___ Advised to call PCP
    ___ Advised to go to the ED
    ___ Advised to call DE
    ___ Advised to call specialist physician
    ___ Other:_______________________________________________________________
  • What followup action did you take?
    ___ Called hospital physician and called patient/caregiver back
    ___ Called DE and called patient/caregiver back
    ___ Called outpatient pharmacy and called patient/caregiver back
    ___ Other:_______________________________________________________________

  Medicine 2:_________________________________________________________________

  Problem:___________________________________________________________________
  ___ Intentional nonadherence
  ___ Inadvertent nonadherence
  ___ System/provider error
  • What recommendation did you make to the patient/caregiver?

    ___ No change needed in discharge plan as it relates to the drug therapy
    ___ Educated patient/caregiver on proper administration, what to do about side effects, etc.
    ___ Advised to call PCP
    ___ Advised to go to the ED
    ___ Advised to call DE
    ___ Advised to call specialist physician
    ___ Other:_______________________________________________________________

  • What followup action did you take?
    ___ Called hospital physician and called patient/caregiver back
    ___ Called DE and called patient/caregiver back
    ___ Called outpatient pharmacy and called patient/caregiver back
    ___ Other:_______________________________________________________________

• Medicine 3:_________________________________________________________________

  Problem:___________________________________________________________________
  ___ Intentional nonadherence
  ___ Inadvertent nonadherence
  ___ System/provider error
  • What recommendation did you make to the patient/caregiver?

    ___ No change needed in discharge plan as it relates to the drug therapy
    ___ Educated patient/caregiver on proper administration, what to do about side effects, etc.
    ___ Advised to call PCP
    ___ Advised to go to the ED
    ___ Advised to call DE
    ___ Advised to call specialist physician
    ___ Other:_______________________________________________________________

  • What followup action did you take?
    ___ Called hospital physician and called patient/caregiver back
    ___ Called DE and called patient/caregiver back
    ___ Called outpatient pharmacy and called patient/caregiver back
    ___ Other:_______________________________________________________________

C. Clarification of Appointments

Potential barriers to attendance identified: ___ Y ___ N

List:__________________________________________________________________________

Potential solutions/resources identified: ___ Y  ___ N

List:__________________________________________________________________________

Alternative plan made: ___ Y ___ N Details:____________________________________________

Clinician/DE informed: ___ Y ___ N Details:____________________________________________

D. Coordination of Postdischarge Home Services (if applicable)

Document any postdischarge services that need to be checked on and who will be doing that (caller/patient/caregiver).

E. Problems

Did patient/caregiver know what constituted an emergency and what to do if a nonemergent problem arose?

___ Yes       ___ No
If no, document source of confusion:

F. Additional Notes

G. Time

Time for reviewing information prior to phone call:_____________________________________

Time for missed calls/attempts:_____________________________________________________
 

Time for initial phone call:_________________________________________________________
 

Time for talking to other health care providers:
 

Time for followup/subsequent phone calls to patient:____________________________________
 

Time for speaking with family or caregivers:__________________________________________
 

Total time spent:________________________________________________________________

Caller's Signature:_______________________________________________________________