Presentation on theme: "Suzanne Mitchell, MD MS Assistant Professor, Family Medicine"— Presentation transcript:
1 Reducing Readmissions through The Re-Engineered Discharge – (Project RED) Suzanne Mitchell, MD MSAssistant Professor, Family MedicineDepartment of Family Medicine /Boston University School of MedicineMarch 25, 2014Participants: , no code needed
2 The Re-Engineered Discharge (Project RED) March 25, 2014Suzanne Mitchell, MD MSAssistant Professor, Family MedicineDepartment 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 DisseminationThis 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 daysHospital discharge is not-standardized:Loose Ends - pending and post-dc testsCommunication – with PCP, ESL, Health litPoor Information - dc summary quality and availabilityPoor Preparation – knowledge of dx, meds, apptsGreat Variability – day of the weekFragmentation – 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 Within6 MonthsHospitalDischargePatientReadmittedWithin3 MonthsProbabilisticRiskAssessmentProcessMappingFailure Modeand EffectsAnalysisQualitativeRoot CauseSo we used theses methods to carefully look at the process8
9 THE RED INTERVENTION Two key components In Hospital –> Preparation & Education of written planAHCPAfter Discharge – Reinforcement of the planPhone call within 72 hours after dischargeAssess clinical statusReview medications and appointments“Discharge” preparation begins at admission… and continues post discharge with a phone call.99
10 RED Checklist Twelve mutually reinforcing components: Medication reconciliationReconcile dc plan with National GuidelinesFollow-up appointmentsOutstanding testsPost-discharge servicesWritten discharge planWhat to do if problem arisesPatient educationAssess patient understandingDc summary to PCPTelephone ReinforcementProvide Language ServicesAdopted byNational Quality Forumas one of 30"Safe Practices" (SP-11)
11 RCT Methods- Enrollment Criteria: English speaking Have telephone RED InterventionN=37530-dayOutcome DataTelephone CallEMR ReviewEnrollmentN=750RandomizationUsual CareN=375Enrollment Criteria:English speakingHave telephoneAble to independently consentNot admitted from institutionalized settingAdult medical patients admitted to Boston Medical Center (urban academic safety-net hospital)Usual care at BMCNo policy to make PCP appt for patientsProvided with dc summary, typed out sheet with dc info writtenLittle instruction, few minutes with nurse/doctor
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?
18 How well did we deliver intervention RED ComponentIntervention Group (No,%)(N=370) *PCP appointment scheduled346 (94%)AHCP given to patient306 (83%)AHCP/DC Summary faxed to PCP336 (91%)PharmD telephone call completed228 (62%)
19 Primary Outcome: Hospital Utilization within 30d after Discharge Usual Care(n=368)Intervention (n=370)P-valueReadmissionsTotal # of visitsRate (visits/patient/month760.20550.15ED VisitsRate (visits/patient/month)900.24610.16Hospital Utilizations *1660.451160.310.009* Hospital utilization refers to ED + Readmissions
21 Outcome Cost AnalysisCost (dollars)Usual Care(n=368)Intervention (n=370)DifferenceHospital visits412,544268,942+143,602ED visits21,38911,285+10,104PCP visits8,90612,617-3,711Total cost/group442,839292,844+149,995Total cost/subject1,203791+412We saved $412 in outcome costs for each patient given RED
22 Medication Errors at 2 Day Call (n=197) 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 effectsPatient did not fill because of insurance10 (8%)Incorrect AdministrationNo. (%)Wrong frequency/interval39 (21%)Wrong dose on prescription33 (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? ImplicationsShould 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, DementiaHigh risk MedsElderlyLOSCo-morbidityMenSubstance AbuseHealth 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 TimeVirtual Patient AdvocatesEmulate face-to-face communicationDevelop therapeutic alliance-empathy, gaze, posture, gestureTeach AHCPTailoredDo “Teach Back”Can drill downPrint ReportsHigh Risk MedsLovenoxInsulinCharacters: Louise (L) and Elizabeth (R)
29 Overall UsabilityEase of UseOverall Satisfaction
31 Who Would You Rather Receive Discharge Instructions From? 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.”No sig diff (actually v. little difference overall) for HI CL vs. LO CL.1=definitely prefer doc, 4=neutral, 7=definitely prefer agent31
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 REDCan 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 2011Patients given RED -> 500Discharge educator = dedicated RNPost discharge phone call = plan’s care managerResults -> 30 day all cause readmission rateCost savings -> well over 400k
36 RED Implementation – Strategies During hospitalization Formal risk screeningProcess for patient educationDischarge educatorDeveloping and teaching ACHPPharmacistStandardized communicationPrimary care providersOther providersHome careNursing Home
37 RED Implementation – Strategies Prior to Discharge Discharge Nurse EducatorUses checklistAssesses patient understanding of discharge plan(Teach back process used)Care TeamDiscusses discharge plan daily at team huddlePatientReceives individual written discharge planCase manager to round with medical team if at all possible37
38 RED Implementation – Strategies at time of discharge Discharge is not rushed or late in the dayAHCP and discharge summary are sent to PCP officePatient reminded about post discharge phone callphone number for follow-up call confirmedCase manager to round with medical team if at all possible38
39 RED TEAM-based CARE MD team RN team Case Mgmt Unit Coordinator/ Rounding AsstEducate patientConfirm medication planCoordinate post discharge servicesArrange 7-10 days post discharge follow up visitDiscuss outstanding issuesTeach AHCPReview steps to take when problems arisePrepare AHCPReconcile discharge plan with national guidelinesAssess degree of understanding –Teach BackReinforce AHCPhrs post- hospital discharge phone callTransmit AHCP & discharge summary24 hours post dc39
40 Barriers to High Quality Transitions “Heads on Beds”Med reconciliationDischarge summaryHospital-PCP communicationLanguage and health literacyCognitive IssuesPlan delegated to interns
41 Role of Senior Leadership Set the vision and the goalCommunicate CommitmentNewsletter, grand rounds, M+M, RCA, sProvide resources & staffCreate implementation teamSet policies to integrate across organizational boundariesGet IT on boardHold people accountableRecognize and reward successYour 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…4141
42 Role of Implementation Team Recruit a collaborative, interdisciplinary teamIdentify process owners and change championsStaff EngagementEnergize staffGet buy-inImplement a Plan that will workBuild skills to support and sustain improvementTrouble shoot as RED is rolled outMonitor progress to provide feedbackThe 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”4242
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 HardREDCan decreased hospital use30% overall reduction, NNT = 7.3Saves $412 per patientHealth IT has great potentialTeam-based Efficiency key to implementationDetermining who benefits is important
47 Thank You! Questions firstname.lastname@example.org email@example.com Project RED Website
48 Upcoming RARE Events….Stay tuned for the next RARE Mental Health Webinar’s:April 21, 2014Care Transitions Interventions in Mental HealthHarold Pincus, Columbia UniversityMay 19, 2014In-REACH ProgramElizabeth Keck, Allina HealthJune 26, 2014New York Office of Mental HealthDr. Molly Finnerty