Improving Nursing Home Discharges Phase I

The Beacon Institute will develop a model entitled Improving Nursing Home Discharges Phase 1 which will provide nursing home discharge planners, residents and caregivers with a systematic approach for organizing successful transitions from nursing homes to community settings. Such settings include private homes and supported environments such as assisted living. Our goal is to improve discharge outcomes, thereby helping Maryland nursing homes to comply with new federal requirements, reduce readmissions to hospitals, and improve resident and caregiver satisfaction after discharge.


This grant will produce the follownig items:

  • A three-part tool kit: This will incllude resources for staff, residents, and caregivers.  The tool kit will emphasize identifying risks that can be reduced or prevented by staff, residents, and caregivers.  These 'preventable risks,' which contribute to unnecessary readmissions, may include medication errors, home environment hazards that increase the likelihood of falls, or inadequate nutrition.  
  • A webinar: This webinar will be available for use by nursing homes, which they can use to educate their staff about discharge planning and the use of the tool kit. 
  • Classes: Nurse educators will . conduct meetings and classes with social services and nursing staff to educate them about the tool kit.
  • Questionnaire: A questionnaire will measure the effectiveness of the tool kit in preparing discharges residents and caregivers. 

The tool kit and other resources are expected in the first quarter of 2018.