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Reducing Readmissions through The Re-Engineered Discharge – (Project RED) Suzanne Mitchell, MD MS Assistant Professor, Family Medicine Department of Family.

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Presentation on theme: "Reducing Readmissions through The Re-Engineered Discharge – (Project RED) Suzanne Mitchell, MD MS Assistant Professor, Family Medicine Department of Family."— Presentation transcript:

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) Suzanne Mitchell, MD MS Assistant Professor, Family Medicine Department of Family Medicine / Boston University School of Medicine March 25, 2014

3 Agenda I.The Transition Problem II.How We Got Started III.The RED Process IV.Brief Mention of Health IT? V.Lessons Learned from Dissemination

4 “ 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

5 A Real Discharge Instruction Sheet

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 Analysis Root Cause Analysis

9 THE RED INTERVENTION Two key components In Hospital –> Preparation & Education of written plan In Hospital –> Preparation & Education of written plan AHCP AHCP After Discharge – Reinforcement of the plan After Discharge – Reinforcement of the plan Phone call within 72 hours after discharge Phone call within 72 hours after discharge Assess clinical status Assess clinical status Review medications and appointments Review medications and appointments

10 RED Checklist Twelve mutually reinforcing components: 1.Medication reconciliation 2.Reconcile dc plan with National Guidelines 3.Follow-up appointments 4.Outstanding tests 5.Post-discharge services 6.Written discharge plan 7.What to do if problem arises 8.Patient education 9.Assess patient understanding 10.Dc summary to PCP 11.Telephone Reinforcement 12.Provide Language Services Adopted by National Quality Forum as one of 30 "Safe Practices" (SP-11)

11 Enrollment N=750 Randomization RED Intervention N=375 Usual Care N= 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)

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 scheduled346 (94%) AHCP given to patient306 (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 ED Visits Total # of visits Rate (visits/patient/month) Hospital Utilizations * Total # of visits Rate (visits/patient/month) * Hospital utilization refers to ED + Readmissions

20 Secondary Outcomes Usual Care (n=368) Intervention (n=370) P-Value No. (%) PCP follow-up rate135 (44%)190 (62%)<0.001 Identified dc diagnosis217 (70%)242 (79%)0.017 Identified PCP name275 (89%)292 (95%)0.007 *

21 Outcome Cost Analysis Cost (dollars) Usual Care (n=368) Intervention (n=370) Difference Hospital visits412,544268, ,602 ED visits21,38911,285+10,104 PCP visits8,90612,617-3,711 Total cost/group442,839292, ,995 Total cost/subject1, We saved $412 in outcome costs for each patient given RED

22 Medication Errors at 2 Day Call (n=197) Incorrect AdministrationNo. (%) Wrong frequency/interval39 (21%) Wrong dose on prescription33 (18%) Failure to take medicationNo. (%) Patient did not think s/he needs med19 (15%) Patient did not fill due to cost21 (17%) Patient did not pick up from pharmacy14 (11%) Patient did not get prescription on discharge15 (12%) Patient self-discontinued due to side effects14 (11%) Patient did not fill because of insurance10 (8%) 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 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 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 Health IT to Save Time Characters: Louise (L) and Elizabeth (R)

29 Overall Usability Overall Satisfaction Ease of Use

30

31 Who Would You Rather Receive Discharge Instructions From? 1=definitely prefer doc, 4=neutral, 7=definitely prefer agent 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.”

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 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?

34 Success stories Boston HealthNet plan Period -> calendar year 2011 Period -> calendar year 2011 Patients given RED -> 500 Patients given RED -> 500 –Discharge educator = dedicated RN –Post discharge phone call = plan’s care manager Results -> 30 day all cause readmission rate Results -> 30 day all cause readmission rate Cost savings -> well over 400k Cost savings -> well over 400k

35 RED for Boston HealthNet

36 Formal risk screening Formal risk screening Process for patient education Process for patient education Discharge educator Discharge educator Developing and teaching ACHP Developing and teaching ACHP Pharmacist Pharmacist Standardized communication Standardized communication Primary care providers Primary care providers Other providers Other providers Home care Home care Nursing Home Nursing Home – Strategies During hospitalization RED Implementation – Strategies During hospitalization

37 Discharge Nurse Educator Discharge Nurse Educator Uses checklist Uses checklist Assesses patient understanding of discharge plan Assesses patient understanding of discharge plan (Teach back process used) Care Team Care Team Discusses discharge plan daily at team huddle Discusses discharge plan daily at team huddle Patient Patient Receives individual written discharge plan Receives individual written discharge plan RED Implementation – Strategies Prior to Discharge

38 Discharge is not rushed or late in the day Discharge is not rushed or late in the day AHCP and discharge summary are sent to PCP office AHCP and discharge summary are sent to PCP office Patient reminded about post discharge phone call Patient reminded about post discharge phone call phone number for follow-up call confirmed phone number for follow-up call confirmed RED Implementation – Strategies at time of discharge

39 RED TEAM-based CARE MD teamRN teamCase MgmtUnit Coordinator/ Rounding Asst Educate patientConfirm medication plan Coordinate post discharge services Arrange 7-10 days post discharge follow up visit Discuss outstanding issues Teach AHCPReview 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

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 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 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 Thank you!

47 Questions Project RED Website Thank You!

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,


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