Reducing Readmissions through The Re-Engineered Discharge –

(Project RED)

Suzanne Mitchell, MD MSAssistant 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)

Suzanne Mitchell, MD MSAssistant Professor, Family MedicineDepartment of Family Medicine / Boston University School of Medicine

March 25, 2014

Agenda

I. The Transition ProblemII. How We Got Started III. The RED ProcessIV. Brief Mention of Health IT?V. Lessons Learned from Dissemination

“Perfect Storm" of Patient Safety

• 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

• 39.5 million hospital discharges/year = Costs totaling $329.2b!• 20% readmitted within 30 days

• Hospital discharge is not-standardized:

“Perfect Storm" of Patient Safety

A Real Discharge Instruction Sheet

ResearchQuestionsWe 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 Within6 Months

HospitalDischarge

Patient Readmitted

Within 3 Months

Probabilistic Risk

Assessment

Process Mapping

Failure Mode and Effects

Analysis

QualitativeAnalysis

Root CauseAnalysis

THE RED INTERVENTIONTHE RED INTERVENTIONTwo key componentsTwo key components

• In HospitalIn Hospital –> Preparation & Education of written plan –> Preparation & Education of written plan

• AHCPAHCP

• After DischargeAfter Discharge – Reinforcement of the plan – Reinforcement of the plan

• Phone call within 72 hours after dischargePhone call within 72 hours after discharge

• Assess clinical statusAssess clinical status

• Review medications and appointmentsReview medications and appointments

RED ChecklistTwelve mutually reinforcing components:

1. Medication reconciliation 2. Reconcile dc plan with National Guidelines3. Follow-up appointments4. Outstanding tests 5. Post-discharge services6. Written discharge plan7. What to do if problem arises8. Patient education9. Assess patient understanding10. Dc summary to PCP11. Telephone Reinforcement12. Provide Language Services

Adopted by

National Quality Forum

as one of 30

"Safe Practices" (SP-11)

EnrollmentN=750

Randomization

RED InterventionN=375

Usual CareN=375

30-day Outcome Data•Telephone Call•EMR Review

RCT Methods-

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

Usual Care (n=368)

Intervention (n=370)

P-value

ReadmissionsTotal # of visitsRate (visits/patient/month

76

0.2055

0.15

ED VisitsTotal # of visitsRate (visits/patient/month)

900.24

610.16

Hospital Utilizations *Total # of visits Rate (visits/patient/month)

1660.45

1160.31 0.009

* Hospital utilization refers to ED + Readmissions

Secondary Outcomes

Usual Care(n=368)

Intervention (n=370)

P-ValueNo. (%) No. (%)

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

Total cost/group 442,839 292,844 +149,995

Total cost/subject 1,203 791 +412

We saved $412 in outcome costs for each patient given We saved $412 in outcome costs for each patient given REDRED

Medication Errors at 2 Day Call (n=197)

Incorrect Administration No. (%)

Wrong frequency/interval 39 (21%)

Wrong dose on prescription 33 (18%)

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%)

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?

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

LovenoxInsulin

Health IT to Save Time

Characters: Louise (L) and Elizabeth (R)

Overall Usability

Overall SatisfactionEase of Use

Who Would You Rather Receive Discharge Instructions From?

1=definitely prefer doc, 4=neutral, 7=definitely prefer agent

36% prefer Louise48% neutral16% 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.”

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 storiesSuccess storiesBoston HealthNet planBoston HealthNet plan

Period -> calendar year 2011Period -> calendar year 2011

Patients given RED -> 500Patients given RED -> 500– Discharge educator = dedicated RNDischarge educator = dedicated RN– Post discharge phone call = plan’s care managerPost discharge phone call = plan’s care manager

Results -> 30 day all cause readmission rateResults -> 30 day all cause readmission rate

Cost savings -> well over 400kCost savings -> well over 400k

RED for Boston HealthNet

• Formal risk screeningFormal risk screening

• Process for patient educationProcess for patient education• Discharge educatorDischarge educator

• Developing and teaching ACHPDeveloping and teaching ACHP• PharmacistPharmacist

• Standardized communicationStandardized communication• Primary care providersPrimary care providers• Other providersOther providers

• Home careHome care• Nursing HomeNursing Home

RED Implementation – – Strategies During hospitalizationStrategies During hospitalization

• Discharge Nurse EducatorDischarge Nurse Educator• Uses checklist Uses checklist • Assesses patient understanding of discharge planAssesses patient understanding of discharge plan

(Teach back process used)(Teach back process used)• Care TeamCare Team

• Discusses discharge plan Discusses discharge plan dailydaily at team huddle at team huddle

• PatientPatient• Receives individual written discharge planReceives individual written discharge plan

RED Implementation – Strategies Prior to Discharge

• Discharge is not rushed or late in the dayDischarge is not rushed or late in the day

• AHCP and discharge summary are sent to PCP officeAHCP and discharge summary are sent to PCP office

• Patient reminded about post discharge phone callPatient reminded about post discharge phone call

• phone number for follow-up call confirmedphone number for follow-up call confirmed

RED Implementation – Strategies at time of discharge

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 post- hospital discharge phone call

Transmit AHCP & discharge summary

24 hours post dc

Barriers to High Quality Transitions

• “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

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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

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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!

brian.jack@bmc.orghttp://www.bu.edu/fammed/projectred/

Questionssuzanne.mitchell@bmc.org

brian.jack@bmc.org

Project RED Website

http://www.bu.edu/fammed/projectred/

Thank You!

Upcoming RARE Events….

Stay tuned for the next RARE Mental Health Webinar’s:

April 21, 2014 Care Transitions Interventions in Mental HealthHarold Pincus, Columbia University

May 19, 2014 In-REACH ProgramElizabeth Keck, Allina Health

June 26, 2014New York Office of Mental HealthDr. Molly Finnerty

Future webinars…

To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact:

Kathy Cummings, kcummings@icsi.org

Jill Kemper, jkemper@icsi.org