{"id":75394,"date":"2025-02-25T15:57:35","date_gmt":"2025-02-25T23:57:35","guid":{"rendered":"https:\/\/www.qualityhealth.org\/bree\/?page_id=75394"},"modified":"2026-01-27T17:38:21","modified_gmt":"2026-01-28T01:38:21","slug":"care-transitions","status":"publish","type":"page","link":"https:\/\/www.qualityhealth.org\/bree\/care-transitions\/","title":{"rendered":"Care Transitions"},"content":{"rendered":"

[vc_row overlay_dotted=”” el_id=”Care_transitions_row”][vc_column][vc_column_text]Please access the Bree Hospital Readmission Report (2014) here.\u00a0<\/a>[\/vc_column_text][vc_separator color=”custom” border_width=”10″ accent_color=”#145e61″][vc_tta_tour style=”outline” shape=”square” color=”black” spacing=”20″ active_section=”1″ no_fill_content_area=”true” title=”Complex Discharge from the Hospital” el_id=”complex-discharge-tour”][vc_tta_section title=”Guideline Information” tab_id=”1703185938862-6ef8c1b4-48be”][vc_column_text]<\/p>\n

Guideline title: Complex Discharge from the Hospital Report and Guidelines<\/h4>\n

Publication Status:<\/strong> Active<\/p>\n

Date of publication<\/strong>: January 2024<\/p>\n

Date of last evidence search: <\/strong>2023<\/p>\n

Scope: <\/strong>Common definition, data collection standards, barrier identification, cross-sector communication<\/p>\n

Methods:<\/strong> Current guidelines and literature review and expert consensus<\/p>\n

Description:<\/strong> 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.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”Read On-line” tab_id=”1703185939268-c6cb0752-74a5″][vc_column_text]<\/p>\n

Complex Patient Discharge Report and Guidelines<\/a><\/h3>\n

[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”Implementation Checklists by Audience” tab_id=”1703185940930-dc2852ff-c700″][vc_column_text]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\u2019 setting. Bree staff co-created the checklists with report workgroup members and topic experts.[\/vc_column_text][vc_toggle title=”Delivery Site and Health System Checklists”]Level 1<\/a><\/p>\n

Level 2<\/a><\/p>\n

Level 3<\/a>[\/vc_toggle][vc_toggle title=”Health Plan Checklists”]Level 1<\/a><\/p>\n

Level 2<\/a><\/p>\n

Level 3<\/a>[\/vc_toggle][\/vc_tta_section][vc_tta_section title=”Resources and Tools” tab_id=”1703185951254-77b84feb-ea14″][vc_toggle title=”Resources and Tools”]AHA Private-Sector Hospital Discharge Tools<\/a><\/p>\n

Re-Engineered Discharge (RED) Toolkit<\/a><\/p>\n

CARE Tool Discharge\u00a0<\/a>[\/vc_toggle][vc_video link=”https:\/\/youtu.be\/mFt6Wj1QcCU” title=”Related Bree Webinars Link”][\/vc_tta_section][vc_tta_section title=”Metrics and Evaluation Resources” tab_id=”1703185969474-3f312751-b80e”][vc_column_text css=””]<\/p>\n

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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.)<\/p>\n

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 \u201caudience\u201d type that is relevant. For example, large health systems may want to track progress at both the organizational level and the individual practitioner level.<\/p>\n

Score cards are also aligned with the Bree Collaboratives\u2019 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.<\/p><\/div>\n<\/div>\n

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.<\/p>\n

Organizations that are interested in participating in case studies\u00a0 can contact the Evaluation and Measurement Manager, Karie Nicholas at knicholas@qualityhelath.org.[\/vc_column_text][vc_toggle title=”Hospitals”]Score Cards Complex Discharge_hospitals<\/a>[\/vc_toggle][vc_toggle title=”Post Acute Care (SNFs)”]Score Card for Complex Discharge Post_acute care<\/a>[\/vc_toggle][vc_toggle title=”Adult Family Homes and Assisted Living Facilities”]Adult family homes and assisted living facilities\u00a0 Complex discharge_AFH_ALF<\/a>[\/vc_toggle][vc_toggle title=”Health Plan”]Score Cards complex discharge_health plans<\/a>[\/vc_toggle][vc_toggle title=”Washington State Agencies”]Washington State Health Care Authority Complex Discharge_HCA<\/a><\/p>\n

Washington State DSHS Complex discharge_DSHS<\/a><\/p>\n

All other Washington State Departments Complex discharge WA State Depts<\/a>[\/vc_toggle][vc_toggle title=”General Score Cards”]Equity Score Card Complex discharge_Equity<\/a>[\/vc_toggle][\/vc_tta_section][vc_tta_section title=”Examples of Implementation – NEW!” tab_id=”1703185999163-6ccd13bf-5a97″][vc_column_text css=””]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.<\/p>\n

Key components of the Complex Discharge model of care tested by the pilot include:
\n\u27a2 ECM Team: Two hospital-based ECM staff each with a capped caseload (1:15 ECM staff-patient
\nratio), developed patient care plans, and navigated access across settings.
\n\u27a2 Partnerships with Post-Discharge Providers: Hospitals participating in the Pilot worked with
\ncommunity providers and contracted with dedicated SNFs to provide payments and other
\nresources to support individuals with complex needs.
\n\u27a2 Supportive Services: Pilot sites had access to funding for supportive services to address patient-
\nlevel barriers to discharge, allowing flexibility in addressing barriers to discharge.9 These funds
\nwere used for non-Medicaid covered services or for covered services that could not be accessed
\ntimely.
\n\u27a2 DSHS Staffing: A DSHS case manager was dedicated to each pilot site with a capped caseload
\n(1:30 case manager-client ratio) to support completion of HCS assessments, person-centered care
\nplanning, and navigation to access to long-term care services and supports. In addition, DSHS
\npublic benefit specialists were dedicated to pilot to support financial eligibility determinations.
\n\u27a2 Multidisciplinary Care Team: To implement the care plan, a multidisciplinary care team involving
\ncross-system partners convened weekly to coordinate care. This team included ECM staff, DSHS
\nstaff, MCOs, SNF partners, and others involved in the patient\u2019s care, such as durable medical
\nequipment (DME) specialists or contracted behavioral support and chemical dependency
\ncounselors.<\/p>\n

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.<\/p>\n

Excerpts from the Washington Complex Discharge Task Force report on the Complex Discharge Pilot and recommendations:<\/h3>\n

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.<\/p>\n

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.<\/p>\n

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.<\/p>\n

The full Task Force Report and results can be found HERE<\/a>.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”Workgroup Members” tab_id=”1739468430250-828e9385-19e3″][vc_column_text css=””]<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Member<\/strong><\/th>\nTitle<\/strong><\/th>\nOrganization<\/strong><\/th>\n<\/tr>\n
Darcy Jaffe, ARNP<\/td>\nSenior Vice President, Safety and Quality<\/td>\nWashington State Hospital Association<\/td>\n<\/tr>\n
Shelley Bogart<\/td>\nBenefits Integration & Community Hospital Program Manager<\/td>\nDepartment of Social and Human Services – Developmental Disabilities Administration<\/td>\n<\/tr>\n
Gloria Brigham, EdD, MN, RN<\/td>\nDirector of Nursing Practice<\/td>\nWashington State Nurses Association<\/td>\n<\/tr>\n
Amy Cole, MBA<\/td>\nHealthcare Executive<\/td>\nMultiCare<\/td>\n<\/tr>\n
Jay Cook, MD, MBA<\/td>\nChief Medical Officer<\/td>\nProvidence<\/td>\n<\/tr>\n
Billie Dickinson<\/td>\nAssociate Director, Policy<\/td>\nWashington State Medical Association<\/td>\n<\/tr>\n
Kelli Emans<\/td>\nIntegration Unit Manager<\/td>\nDepartment of Social and Human Services – Home and Community Services<\/td>\n<\/tr>\n
Jeff Foti, MD<\/td>\nMedical Director, Inpatient Care Coordination<\/td>\nSeattle Children’s<\/td>\n<\/tr>\n
Jas Grewal, RN<\/td>\n<\/td>\nWashington Health Care Authority<\/td>\n<\/tr>\n
Karla Hall, RN<\/td>\nPalliative Care Program Coordinator<\/td>\nPeaceHealth<\/td>\n<\/tr>\n
Kathleen Heim, MSN, RN<\/td>\nNursing Director<\/td>\nPeaceHealth<\/td>\n<\/tr>\n
Carol Hiner, MSN<\/td>\nRegional Director of Network Hospital Operations<\/td>\nKaiser Permanente<\/td>\n<\/tr>\n
Linda Keenan, PhD, MPA, BSN, RN-BC<\/td>\nChief Nursing Officer<\/td>\nUnited Healthcare<\/td>\n<\/tr>\n
Jen Koon, MD<\/td>\nAssociate Medical Director<\/td>\nPremera Blue Cross<\/td>\n<\/tr>\n
Danica Koos, MPH<\/td>\nProgram Manager, Care Improvement<\/td>\nCommunity Health Plan of Washington<\/td>\n<\/tr>\n
Cathy MacEnraw, MSW<\/td>\nDirector of Social Work<\/td>\nProvidence<\/td>\n<\/tr>\n
Elena Madrid, RN<\/td>\nExecutive Vice President of Education and Regulatory Affairs<\/td>\nWashington Home Care Association (WHCA)<\/td>\n<\/tr>\n
Colin Maloney, MPH<\/td>\nCommunity Health Strategies for Homelessness Manager<\/td>\nWashington Department of Health<\/td>\n<\/tr>\n
Amber May, MD<\/td>\nPediatrician<\/td>\nKaiser Permanente<\/td>\n<\/tr>\n
Liz McCully, MSW<\/td>\nSocial Work Case Manager<\/td>\nSwedish<\/td>\n<\/tr>\n
Jason McGill, JD<\/td>\nAssistant Director<\/td>\nWHCA<\/td>\n<\/tr>\n
Kellie Meserve, MN, RN<\/td>\nDivision Director, Care Coordination<\/td>\nVirginia Mason Franciscan Health<\/td>\n<\/tr>\n
Tracey Mullian, MSW<\/td>\nSocial Work Case Manager<\/td>\nSwedish<\/td>\n<\/tr>\n
Kim Petram, BSN<\/td>\nDirector, Case Management<\/td>\nValley Medical Center<\/td>\n<\/tr>\n
Lou Reyes<\/td>\n<\/td>\nSwedish<\/td>\n<\/tr>\n
Sheridan Rieger, MD<\/td>\nMarket Medical Director<\/td>\nConcerto Health<\/td>\n<\/tr>\n
Odilliah Sangali<\/td>\nCommunity Health Strategies for Homelessness<\/td>\nWashington Department of Health<\/td>\n<\/tr>\n
Zosia Stanley, JD, MHA<\/td>\nVice President and Associate General Counsel<\/td>\nWashington State Hospital Association<\/td>\n<\/tr>\n
Cyndi Stilson, RN, BSN<\/td>\nManager, Transitions of Care<\/td>\nCommunity Health Plan of Washington<\/td>\n<\/tr>\n
Ric Troyer, MD<\/td>\nCare Team Medical Director<\/td>\nIora Health<\/td>\n<\/tr>\n
Janice Tufte<\/td>\nFamily Advisor<\/td>\nPCORI West Ambassador, Hassanah Consulting<\/td>\n<\/tr>\n
Azmera Telahun<\/td>\nAssociate Chief Nurse Officer-Care Management and Social Work<\/td>\nUniversity of Washington<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”Archived Meeting Materials” tab_id=”1740099896468-92164722-a841″][vc_column_text css=””]<\/p>\n

Past Meeting Materials<\/h3>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Date<\/strong><\/td>\nMaterials<\/strong><\/td>\n<\/tr>\n
January 2023<\/td>\nJanuary Agenda<\/a>
\nDraft Charter and Roster<\/a>
\nHCA Legislative Presentation<\/a><\/td>\n<\/tr>\n
February<\/td>\nFebruary Agenda<\/a>
\nJanuary Minutes<\/a>
\nDiscussion Slides<\/a>
\nDraft Charter Roster<\/a><\/td>\n<\/tr>\n
March<\/td>\nMarch Agenda<\/a>
\nFebruary Minutes<\/a>
\nDischarge Glossary<\/a>
\nWorkgroup Survey Results<\/a><\/td>\n<\/tr>\n
April<\/td>\nApril Agenda<\/a>
\nMarch Minutes<\/a>
\nCommon Barriers Framework<\/a>
\nDraft Sample Discharge Metrics<\/a><\/td>\n<\/tr>\n
May<\/td>\nMay Agenda<\/a>
\nApril Minutes<\/a>
\nDraft Data Recommendations<\/a>
\nDraft Evidence Review Table<\/a><\/td>\n<\/tr>\n
June<\/td>\nJune Agenda<\/a>
\nMay Minutes<\/a>
\nDraft Data Recommendations<\/a>
\nDraft Evidence Review Table<\/a>
\nDischarge Discussion Slides<\/a><\/td>\n<\/tr>\n
July<\/td>\nJuly Agenda<\/a>
\nJune Minutes<\/a>
\nDraft Recommendations 0720<\/a>
\nComplex Discharge Evidence Table 0720<\/a><\/td>\n<\/tr>\n
August<\/td>\nAugust Agenda<\/a>
\nJuly Minutes<\/a>
\nDraft Recommendations 0817<\/a><\/td>\n<\/tr>\n
September<\/td>\nSeptember Agenda<\/a>
\nAugust Minutes<\/a>
\nDraft Recommendations 0921<\/a><\/td>\n<\/tr>\n
October<\/td>\nOctober Agenda<\/a>
\nSeptember Minutes<\/a>
\nDraft Recommendations 1019<\/a><\/td>\n<\/tr>\n
November<\/td>\nNovember Agenda<\/a>
\nOctober Minutes<\/a>
\nDraft Recommendations 1109<\/a><\/td>\n<\/tr>\n
December<\/td>\nDecember Agenda<\/a>
\nNovember Minutes<\/a>
\nScorecard<\/a><\/td>\n<\/tr>\n
January 2024<\/td>\nJanuary Agenda<\/a>
\nDecember Minutes<\/a>
\nDraft Recommendations<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
Read our Charter<\/div>\n

[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”Award Winners” tab_id=”1739468431125-9e10206d-c540″][vc_column_text css=””]Award winners for Best Practices in Potentially Avoidable Hospital Readmissions:<\/p>\n

 <\/p>\n

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