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.
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
| 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 |
Past Meeting Materials
Award winners for Best Practices in Potentially Avoidable Hospital Readmissions:
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