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Reducing Readmissions through
The Re-Engineered Discharge –
(Project RED)
Suzanne Mitchell, MD MS
Assistant Professor, Family Medicine
Department of Family Medicine /
Boston University School of Medicine
March 25, 2014
Participants:1-866-639-0744, no code needed
The Re-Engineered Discharge
(Project RED)
March 25, 2014
Suzanne Mitchell, MD MS
Assistant Professor, Family Medicine
Department of Family Medicine /
Boston University School of Medicine
Agenda
I.
II.
III.
IV.
V.
The Transition Problem
How We Got Started
The RED Process
Brief Mention of Health IT?
Lessons Learned from Dissemination
“Perfect
Storm"
Patient
Safety
“Perfect
Storm"
of of
Patient
Safety
• 39.5 million hospital discharges/year = Costs totaling $329.2b!
• 20% readmitted within 30 days
• Hospital discharge is not-standardized:
•
•
•
•
•
•
Loose Ends - pending and post-dc tests
Communication – with PCP, ESL, Health lit
Poor Information - dc summary quality and availability
Poor Preparation – knowledge of dx, meds, appts
Great Variability – day of the week
Fragmentation – who is in charge?
• Hospital Discharge is not safe!
• 19% of patients have a post-discharge AE
A Real Discharge Instruction Sheet
ResearchQuestions
We asked:
• Can improving the discharge process reduce adverse events and
unplanned hospital utilization?
Grant reviewer asked:
• What is the “discharge process”?
Question for you……
• Do you know what your hospital’s discharge process is?
• Do you know the parts of the process where problems are
occurring for patients or hospital personnel?
• ie, occurring before or following discharge?
• How are you identifying the problem spots?
Principles of the RED:
Creating the Toolkit
Readmission Within
6 Months
Patient
Readmitted
Within
3 Months
Hospital
Discharge
Probabilistic
Risk
Assessment
Process
Mapping
Failure Mode
and Effects
Analysis
Qualitative
Analysis
Root Cause
Analysis
THE RED INTERVENTION
Two key components
• In Hospital –> Preparation & Education of written plan
• AHCP
• After Discharge – Reinforcement of the plan
• Phone call within 72 hours after discharge
• Assess clinical status
• Review medications and appointments
RED Checklist
Twelve mutually reinforcing components:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Medication reconciliation
Reconcile dc plan with National Guidelines
Follow-up appointments
Outstanding tests
Adopted by
Post-discharge services
National Quality
Written discharge plan
Forum
What to do if problem arises
Patient education
as one of 30
Assess patient understanding
"Safe Practices"
Dc summary to PCP
(SP-11)
Telephone Reinforcement
Provide Language Services
RCT MethodsRED Intervention
N=375
Enrollment
N=750
Randomization
Usual Care
N=375
30-day
Outcome Data
•Telephone Call
•EMR Review
Enrollment Criteria:
•English speaking
•Have telephone
•Able to independently consent
•Not admitted from institutionalized setting
•Adult medical patients admitted to Boston Medical
Center (urban academic safety-net hospital)
Personalized cover page
MEDICATION PAGE (2 of 3)
APPOINTMENTS PAGE
PRIMARY DIAGNOSIS PAGE
Question for you……
• Does your institution have a patient-centered discharge
document?
• If no, what are the barriers to providing such a document?
• If yes,
• What are the design elements that facilitate communication?
• What design elements support patient self-management?
FINDINGS from
Project RED RCT
How well did we deliver intervention
RED Component
Intervention Group (No,%)
(N=370) *
PCP appointment scheduled
346 (94%)
AHCP given to patient
306 (83%)
AHCP/DC Summary faxed to
PCP
336 (91%)
PharmD telephone call
completed
228 (62%)
Primary Outcome:
Hospital Utilization within 30d after Discharge
Readmissions
Total # of visits
Rate
(visits/patient/month
Usual Care
(n=368)
Intervention
(n=370)
76
0.20
55
0.15
90
0.24
61
0.16
166
0.45
116
0.31
P-value
ED Visits
Total # of visits
Rate (visits/patient/month)
Hospital Utilizations *
Total # of visits
Rate (visits/patient/month)
* Hospital utilization refers to ED + Readmissions
0.009
Secondary Outcomes
Usual Care
(n=368)
Intervention
(n=370)
No. (%)
No. (%)
P-Value
PCP follow-up rate
135 (44%)
190 (62%)
<0.001
Identified dc diagnosis
217 (70%)
242 (79%)
0.017
Identified PCP name
275 (89%)
292 (95%)
0.007
*
Outcome Cost Analysis
Cost (dollars)
Usual Care
(n=368)
Intervention
(n=370)
Difference
Hospital visits
412,544
268,942
+143,602
ED visits
21,389
11,285
+10,104
PCP visits
8,906
12,617
-3,711
442,839
292,844
+149,995
1,203
791
+412
Total cost/group
Total cost/subject
We saved $412 in outcome costs for each patient given
RED
Medication Errors at 2 Day Call (n=197)
Failure to take medication
No. (%)
Patient did not think s/he needs med
19 (15%)
Patient did not fill due to cost
21 (17%)
Patient did not pick up from pharmacy
14 (11%)
Patient did not get prescription on discharge
15 (12%)
Patient self-discontinued due to side effects
14 (11%)
Patient did not fill because of insurance
10 (8%)
Incorrect Administration
No. (%)
Wrong frequency/interval
39 (21%)
Wrong dose on prescription
33 (18%)
Overall, 51% experienced error within 2 days!
Question for you…..
• Have you tried any strategies to communicate with patients
following discharge?
• Are you able to make PCP appointments at the time of
discharge?
• What strategies are you using for medication reconciliation at
the time of discharge?
Implications
Should all patients get RED?
Question for you…..
• Is your institution doing risk stratification
at the time of admission?
Who is at risk of Rehospitalization?
• CHF, COPD, Dementia
• High risk Meds
• Elderly
• LOS
• Co-morbidity
• Men
• Substance Abuse
• Health Literacy
(REALM)
• Depression (PHQ-9)
• Patient Activation
(PAM)
• Frequent Fliers (>2 in
6 months)
Can Health IT assist with providing
a comprehensive discharge?
Health IT to Save Time
Virtual Patient Advocates
• Emulate face-to-face communication
• Develop therapeutic alliance-empathy, gaze, posture, gesture
• Teach AHCP
• Tailored
• Do “Teach Back”
• Can drill down
• Print Reports
• High Risk Meds
Lovenox
Insulin
Characters: Louise (L) and Elizabeth (R)
Overall Usability
Overall Satisfaction
Ease of Use
Who Would You Rather Receive
Discharge Instructions From?
36% prefer Louise
48% neutral
16% prefer doc or nurse
“I prefer Louise, she’s better
than a doctor, she explains
more, and doctors are always
in a hurry.”
“It was just like a nurse,
actually better, because
sometimes a nurse just gives
you the paper and says ‘Here
you go.’ Elizabeth explains
everything.”
1=definitely prefer doc, 4=neutral, 7=definitely prefer agent
Question for you…..
• Is your institution using health IT to streamline the hospital
discharge process?
• What processes are you automating?
• What are the benefits/challenges of using health IT for
discharge process?
Barriers to RED
• Can appointments be made?
• Will RED delay discharge time?
• Who serves as the Discharge Educator?
• Who does the 2 day phone call?
• Who Produces the AHCP?
Can we Re-Engineer the Hospital Ward?
Success stories
Boston HealthNet plan
Period -> calendar year 2011
Patients given RED -> 500
– Discharge educator = dedicated RN
– Post discharge phone call = plan’s care manager
Results -> 30 day all cause readmission rate
Cost savings -> well over 400k
RED for Boston HealthNet
RED Implementation –
Strategies During hospitalization
• Formal risk screening
• Process for patient education
• Discharge educator
• Developing and teaching ACHP
• Pharmacist
• Standardized communication
• Primary care providers
• Other providers
• Home care
• Nursing Home
RED Implementation –
Strategies Prior to Discharge
• Discharge Nurse Educator
• Uses checklist
• Assesses patient understanding of discharge plan
(Teach back process used)
• Care Team
• Discusses discharge plan daily at team huddle
• Patient
• Receives individual written discharge plan
RED Implementation –
Strategies at time of discharge
• Discharge is not rushed or late in the day
• AHCP and discharge summary are sent to PCP office
• Patient reminded about post discharge phone call
• phone number for follow-up call confirmed
RED TEAM-based CARE
MD team
RN team
Case Mgmt
Unit Coordinator/
Rounding Asst
Educate patient
Confirm medication
plan
Coordinate post
discharge services
Arrange 7-10 days
post discharge follow
up visit
Discuss outstanding
issues
Teach AHCP
Review steps to take
when problems arise
Prepare AHCP
Reconcile discharge
plan with national
guidelines
Assess degree of
understanding –
Teach Back
Reinforce AHCP
24-48 hrs posthospital discharge
phone call
Transmit AHCP &
discharge summary
24 hours post dc
Barriers to High Quality Transitions
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•
•
•
•
•
•
“Heads on Beds”
Med reconciliation
Discharge summary
Hospital-PCP communication
Language and health literacy
Cognitive Issues
Plan delegated to interns
Role of Senior Leadership
• Set the vision and the goal
• Communicate Commitment
• Newsletter, grand rounds, M+M, RCA, emails
• Provide resources & staff
• Create implementation team
• Set policies to integrate across organizational boundaries
• Get IT on board
• Hold people accountable
• Recognize and reward success
41
Role of Implementation Team
• Recruit a collaborative, interdisciplinary team
• Identify process owners and change champions
• Staff Engagement
• Energize staff
• Get buy-in
•
•
•
•
Implement a Plan that will work
Build skills to support and sustain improvement
Trouble shoot as RED is rolled out
Monitor progress to provide feedback
42
Question for you…..
• What barriers or facilitators have you
faced in helping to manage your hospital
discharge process better?
Conclusions
• Hospital DC is low hanging fruit
• Changing the Culture of Hospitals is Hard
• RED
• Can decreased hospital use
• 30% overall reduction, NNT = 7.3
• Saves $412 per patient
• Health IT has great potential
• Team-based Efficiency key to implementation
• Determining who benefits is important
QUESTIONS FOR ME??
Thank you!
[email protected]
http://www.bu.edu/fammed/projectred/
Thank You!
Questions
[email protected]
[email protected]
Project RED Website
http://www.bu.edu/fammed/projectred/
Upcoming RARE Events….
Stay tuned for the next RARE Mental Health Webinar’s:
April 21, 2014
Care Transitions Interventions in Mental Health
Harold Pincus, Columbia University
May 19, 2014
In-REACH Program
Elizabeth Keck, Allina Health
June 26, 2014
New York Office of Mental Health
Dr. Molly Finnerty
Future webinars…
To suggest future topics for this series,
Reducing Avoidable Readmissions
Effectively “RARE” Networking
Webinars, contact:
Kathy Cummings, [email protected]
Jill Kemper, [email protected]