Please access the Bree Hospital Readmission Report (2014) here.
Care Transitions
Complex Discharge from the Hospital
Guideline title: Complex Discharge from the Hospital Report and Guidelines
Publication Status: Active
Date of publication: January 2024
Date of last evidence search: 2023
Scope: Common definition, data collection standards, barrier identification, cross-sector communication
Methods: Current guidelines and literature review and expert consensus
Description: To ensure consistency in efforts to address complex patient discharges across the state, the workgroup decided to establish a common definition for complex patient discharge that will be transferable across settings and supports alignment of efforts to prevent and address complex patient discharges across sectors.
The checklist tool translates the Bree guidelines into action steps for that sector (i.e., clinician, health delivery site, public health, etc.). The action items have been arranged into levels 1, 2, and 3 to correspond to the difficulty level of implementing the action into the sectors’ setting. Bree staff co-created the checklists with report workgroup members and topic experts.
To support health system improvement the Bree Collaborative has created score cards that are designed to help measure progress on the implementation of our guidelines. These were developed in collaboration with subject matter experts and are aligned across audience types (such as state agencies, health plans, providers, community organizations, employers, etc.)
To use our score cards, find the audience type, or types, that is closest to your organization or area of improvement work and download the document. There may be more than one “audience” type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.
Score cards are also aligned with the Bree Collaboratives’ self-report data collection efforts. Organizations are not required to report, however anyone can submit data to help track system wide progress, measure their progress against others, and to be eligible for implementation awards.
At this time the Bree is not planning a formal evaluation for this topic, however any organization may still submit score cards for the purpose of data sharing and awards.
Organizations that are interested in participating in case studies can contact the Evaluation and Measurement Manager, Karie Nicholas at knicholas@qualityhelath.org.
Hospitals
Score Cards Complex Discharge_hospitals
Post Acute Care (SNFs)
Score Card for Complex Discharge Post_acute care
Adult Family Homes and Assisted Living Facilities
Adult family homes and assisted living facilities Complex discharge_AFH_ALF
Health Plan
Score Cards complex discharge_health plans
Washington State Agencies
Washington State Health Care Authority Complex Discharge_HCA
Washington State DSHS Complex discharge_DSHS
All other Washington State Departments Complex discharge WA State Depts
General Score Cards
Equity Score Card Complex discharge_Equity
Beginning in 2024, the Washington State Complex Discharge Task Force conducted a pilot with Harborview Medical Center, Peacehealth (Vancouver), Virginia Mason Franciscan Health, MultiCare and Providence Regional Medical Center to test a model of care informed by the Bree Collaborative report on Complex Discharge.
Key components of the Complex Discharge model of care tested by the pilot include:
➢ ECM Team: Two hospital-based ECM staff each with a capped caseload (1:15 ECM staff-patient
ratio), developed patient care plans, and navigated access across settings.
➢ Partnerships with Post-Discharge Providers: Hospitals participating in the Pilot worked with
community providers and contracted with dedicated SNFs to provide payments and other
resources to support individuals with complex needs.
➢ Supportive Services: Pilot sites had access to funding for supportive services to address patient-
level barriers to discharge, allowing flexibility in addressing barriers to discharge.9 These funds
were used for non-Medicaid covered services or for covered services that could not be accessed
timely.
➢ DSHS Staffing: A DSHS case manager was dedicated to each pilot site with a capped caseload
(1:30 case manager-client ratio) to support completion of HCS assessments, person-centered care
planning, and navigation to access to long-term care services and supports. In addition, DSHS
public benefit specialists were dedicated to pilot to support financial eligibility determinations.
➢ Multidisciplinary Care Team: To implement the care plan, a multidisciplinary care team involving
cross-system partners convened weekly to coordinate care. This team included ECM staff, DSHS
staff, MCOs, SNF partners, and others involved in the patient’s care, such as durable medical
equipment (DME) specialists or contracted behavioral support and chemical dependency
counselors.
The pilot was concluded on June 30th, 2025 and preliminary results were reported out. The full report can be found at the end of this section.
Excerpts from the Washington Complex Discharge Task Force report on the Complex Discharge Pilot and recommendations:
Over the last two years, the Complex Discharge Pilot has designed and tested a complex discharge model of care to support Medicaid patient transitions from hospitals into post-acute care and home and community-based settings, including SNFs, assisted living facilities, adult family homes, other community settings, or patient homes. The model focused on a patient-centered approach to coordination of social, behavioral, medical, and long-term care services, beginning in the hospital and following the patient to the next level of care needed.
The pilot included five sites across Washington, with the first site launching in April 2024 and fifth site beginning in January 2025 (see below). While originally envisioned as a two-year pilot, the work to design and launch the pilot required significantly more time and work by partners than anticipated. This included development of a common understanding the pilot goals and expectations, system capacities needed to support care transitions, and greater appreciation of the barriers different parts of the system face in establishing innovative approaches.
Each pilot site had 30 slots for which they could refer patients to the pilot services. Patients eligible for the pilot included Medicaid adults who were medically ready to be transferred outside of an acute care setting but were unable due to transition barriers. Multiple barriers were identified for each individual participating in the pilot.
The full Task Force Report and results can be found HERE.
| Member | Title | Organization |
|---|---|---|
| Darcy Jaffe, ARNP | Senior Vice President, Safety and Quality | Washington State Hospital Association |
| Shelley Bogart | Benefits Integration & Community Hospital Program Manager | Department of Social and Human Services – Developmental Disabilities Administration |
| Gloria Brigham, EdD, MN, RN | Director of Nursing Practice | Washington State Nurses Association |
| Amy Cole, MBA | Healthcare Executive | MultiCare |
| Jay Cook, MD, MBA | Chief Medical Officer | Providence |
| Billie Dickinson | Associate Director, Policy | Washington State Medical Association |
| Kelli Emans | Integration Unit Manager | Department of Social and Human Services – Home and Community Services |
| Jeff Foti, MD | Medical Director, Inpatient Care Coordination | Seattle Children’s |
| Jas Grewal, RN | Washington Health Care Authority | |
| Karla Hall, RN | Palliative Care Program Coordinator | PeaceHealth |
| Kathleen Heim, MSN, RN | Nursing Director | PeaceHealth |
| Carol Hiner, MSN | Regional Director of Network Hospital Operations | Kaiser Permanente |
| Linda Keenan, PhD, MPA, BSN, RN-BC | Chief Nursing Officer | United Healthcare |
| Jen Koon, MD | Associate Medical Director | Premera Blue Cross |
| Danica Koos, MPH | Program Manager, Care Improvement | Community Health Plan of Washington |
| Cathy MacEnraw, MSW | Director of Social Work | Providence |
| Elena Madrid, RN | Executive Vice President of Education and Regulatory Affairs | Washington Home Care Association (WHCA) |
| Colin Maloney, MPH | Community Health Strategies for Homelessness Manager | Washington Department of Health |
| Amber May, MD | Pediatrician | Kaiser Permanente |
| Liz McCully, MSW | Social Work Case Manager | Swedish |
| Jason McGill, JD | Assistant Director | WHCA |
| Kellie Meserve, MN, RN | Division Director, Care Coordination | Virginia Mason Franciscan Health |
| Tracey Mullian, MSW | Social Work Case Manager | Swedish |
| Kim Petram, BSN | Director, Case Management | Valley Medical Center |
| Lou Reyes | Swedish | |
| Sheridan Rieger, MD | Market Medical Director | Concerto Health |
| Odilliah Sangali | Community Health Strategies for Homelessness | Washington Department of Health |
| Zosia Stanley, JD, MHA | Vice President and Associate General Counsel | Washington State Hospital Association |
| Cyndi Stilson, RN, BSN | Manager, Transitions of Care | Community Health Plan of Washington |
| Ric Troyer, MD | Care Team Medical Director | Iora Health |
| Janice Tufte | Family Advisor | PCORI West Ambassador, Hassanah Consulting |
| Azmera Telahun | Associate Chief Nurse Officer-Care Management and Social Work | University of Washington |
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