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.


The following items are products of the award:

  • 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 to educate staff about discharge planning and the use of the tool kit. 
  • Training: Nurse educators will conduct classes with social services and nursing staff to educate them about the tool kit.  The first event was held June 19, 2018, at the Talbot Hospice in Easton, MD, and the second event will be held July 19, 2018 at Williamsport Retirement Village in Williamsport, MD.  Registration is free for these half day (9-12) events but space is limited to 30 students. RSVP to reserve your seat!
  • Questionnaire: A questionnaire will measure the effectiveness of the tool kit in preparing discharges residents and caregivers. 



This Toolkit was produced as part of a grant titled "Improving Nursing Home Discharges Phase I" from 
the Office of Health Care Quality, MDH, Maryland