1. 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: , no code needed

2. 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

3. Agenda The Transition Problem How We Got Started The RED Process
Brief Mention of Health IT?
Lessons Learned from Dissemination
This is what we will discuss today.

4. “Perfect Storm" 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?
N summary – there is great room for improvement in the hospital discharge.
Hospital Discharge is not safe!
19% of patients have a post-discharge AE

5. A Real Discharge Instruction Sheet
This is an example of an actual instructin sheet for a patient being discharges – how couudl anybody nderstand this.

6. ResearchQuestions We asked:
Can improving the discharge process reduce adverse events and unplanned hospital utilization?
Grant reviewer asked:
What is the “discharge process”?

7. 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?

8. Principles of the RED: Creating the Toolkit
Readmission Within
6 Months
Hospital
Discharge
Patient
Readmitted
Within
3 Months
Probabilistic
Risk
Assessment
Process
Mapping
Failure Mode
and Effects
Analysis
Qualitative
Root Cause
So we used theses methods to carefully look at the process 8

9. 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
“Discharge” preparation begins at admission… and continues post discharge with a phone call. 9 9

10. RED Checklist Twelve mutually reinforcing components:
Medication reconciliation
Reconcile dc plan with National Guidelines
Follow-up appointments
Outstanding tests
Post-discharge services
Written discharge plan
What to do if problem arises
Patient education
Assess patient understanding
Dc summary to PCP
Telephone Reinforcement
Provide Language Services
Adopted by
National Quality Forum
as one of 30
"Safe Practices" (SP-11)

11. RCT Methods- Enrollment Criteria: English speaking Have telephone
RED Intervention
N=375
30-day
Outcome Data
Telephone Call
EMR Review
Enrollment
N=750
Randomization
Usual Care
N=375
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)
Usual care at BMC
No policy to make PCP appt for patients
Provided with dc summary, typed out sheet with dc info written
Little instruction, few minutes with nurse/doctor

12. Personalized cover page

13. MEDICATION PAGE (2 of 3)

14. APPOINTMENTS PAGE

15. PRIMARY DIAGNOSIS PAGE

16. 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?

17. FINDINGS from Project RED RCT

18. 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%)

19. Primary Outcome: Hospital Utilization within 30d after Discharge
Usual Care
(n=368)
Intervention (n=370)
P-value
Readmissions
Total # of visits
Rate (visits/patient/month 76
0.20 55
0.15
ED Visits
Rate (visits/patient/month) 90
0.24 61
0.16
Hospital Utilizations *
166
0.45
116
0.31
0.009
* Hospital utilization refers to ED + Readmissions

20. Secondary Outcomes * Usual Care (n=368) Intervention (n=370) P-Value
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 *

21. 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 RED

22. 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
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!

23. 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?

24. Should all patients get RED?
Implications
Should all patients get RED?

25. Question for you…..
Is your institution doing risk stratification at the time of admission?

26. 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)

27. Can Health IT assist with providing a comprehensive discharge?

28. Characters: Louise (L) and Elizabeth (R)
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)

29. Overall Usability
Ease of Use
Overall Satisfaction

31. 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.”
No sig diff (actually v. little difference overall) for HI CL vs. LO CL.
1=definitely prefer doc, 4=neutral, 7=definitely prefer agent 31

32. 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?

33. Can we Re-Engineer the Hospital Ward?
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? 33

34. 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

35. RED for Boston HealthNet

36. 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

37. 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
Case manager to round with medical team if at all possible 37

38. 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
Case manager to round with medical team if at all possible 38

39. 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
hrs post- hospital discharge phone call
Transmit AHCP & discharge summary
24 hours post dc 39

40. 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

41. Role of Senior Leadership
Set the vision and the goal
Communicate Commitment
Newsletter, grand rounds, M+M, RCA, s
Provide resources & staff
Create implementation team
Set policies to integrate across organizational boundaries
Get IT on board
Hold people accountable
Recognize and reward success
Your work will need leadership support as you go along. This will probably include some of your top leaders, but it is also important that clinical leaders in the CHF units demonstrate their commitment and support.
Some of this involves what we think of as “personal” support – communicating that this project is a priority and making the time and space for you to do your work. Some of what you’ll need from leaders is more concrete and practical – such as helping you resolve problems and barriers, providing resources & structure and helping you hold staff accountable for the work that needs to occur to make RED successful… 41 41

42. 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
The most important element is YOU – You have probably worked on improvement teams before so, this is just a reminder t hat clinical process redesign is inter-disciplinary, seeks staff involvement and engagement in planning and implementing changes, is data-driven (you should be measuring as you go along and after you implement the new process) and implementing changes will involve training, communication and “spread” 42 42

43. Question for you…..
What barriers or facilitators have you faced in helping to manage your hospital discharge process better?

44. 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

45. QUESTIONS FOR ME??

46. brian.jack@bmc.org http://www.bu.edu/fammed/projectred/
Thank you!

47. Thank You! Questions suzanne.mitchell@bmc.org brian.jack@bmc.org
Project RED Website

48. 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

49. Future webinars…
To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact: Kathy Cummings, Jill Kemper,