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Small Talks: Enhancing Transitions to Community

February 16, 2022 @ 12:00 pm - 12:30 pm

Transitions back to the community can be fraught with challenges, including unplanned readmissions. Join us to explore how Project RE-Engineered Discharge (Project RED), can support community discharges from the hospital or skilled nursing home.

Community connections are key to successful discharges, so we’ll also discuss screening and addressing social determinants of health to reduce unnecessary readmissions.


  1. Recognize that patients discharged to the community without appropriate community connections are at higher risk of hospital readmissions.
  2. Describe how Project RED, which supports patient and family engagement and helps to make connections for social needs, has been successfully implemented in SNFs.
  3. Be prepared to implement Project RED or one of the tools to address social determinants of health, and connect residents with community resources to decrease readmissions

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