TABLE 4.

Project RED (Re-Engineered Discharge): A Standardized Hospital-based Program Designed to Provide Patients and Caregivers Information to Continue Care at Home

Context	Mechanism	CIMO (Context—Intervention—Mechanism—Outcome)
Patient’s characteristics	Simplifying	These are patients who have been in a hospital and been sleep deprived. They have had maybe hypoxia, an operation, a fever, narcotic medications; so they’re not on the top of the cognitive game … But the after discharge care plan is key because it is like large font and colors and photographs, and the medicines are very clear … so that people can actually do what it takes to care for themselves
Organizational structure (culture) & patient’s characteristics	Verifying	Because, you know, care planning in nursing is a big deal … And that discharge summaries were being treated as care plans. And that we would sometimes, not always, give the discharge summary to the patients, as if they understood any of it. Right? One of the tenants of project RED is that all patients have an appointment when they leave the hospital. It says, when patient is being discharged, the nurse goes into the room with a postcard that has the next 14 d on it and says cross off the days that you are unable to keep an appointment and circle the days that you would be able to make an appointment and write in who is going to take you on those days. So, the chances of them actually keeping the appointment are much greater if the appointment is made in that manner
Relationship/communication between professionals (across settings)	Connecting	So, so one thing we noted, was that communication between the hospital doctors and the community doctor hardly ever happened. Directly, hardly … So I’ve been to hospitals, many of them, that say: Well, we can’t do our discharge summaries at the time of discharge … So, in project RED it is. That’s it. Within 24 hours the information has to be sent from the hospital to the source of ongoing care … And then, but what discharge summary is, is doctor to doctor communication … So it would be more clearly: here is the medicines, here is the diagnosis, here’s the follow up plan, and here is the pending tests. Well, and that is kind of what you need to know. Well, when we sent people to nursing homes with it, we got a lot of feedback from the nursing homes that the nurses really liked it … So then the principal would be having communication with your post discharge source of ongoing care is important

PCP indicates primary care physician.