Oneida Healthcare adopted Project RED (Re-Engineered Discharge) after recognizing a need to address hospital readmissions in high-risk populations. Project RED provides education to patients diagnosed with heart failure (HF), chronic obstructive pulmonary disease (COPD), or pneumonia from admission through discharge with a plan of action to prevent readmission.
At admission, Care Transition Service (CTS)—a team of registered nurses and social workers—discusses medication regimen, primary care providers, and potential referrals, and reviews with them the educational packets they’re given for their specific diseases. Patients receive an After Hospital Care Plan booklet that contains critical information, including: a large-print medication schedule; a list of all providers and the conditions they’re treating; and a calendar with scheduled appointments and prescribed activities and diets.
As a result, Oneida is now below the U.S. average for HF readmissions; well below the U.S. average for pneumonia readmissions—close to the top 10% in the nation (15.7%); and consistently below the U.S. average for COPD readmissions, approaching the top 10% in the nation (18.8%).