1. Project RED The Re-Engineered Discharge
JCR’s AHRQ-funded Project
April 2010

2. Disclaimer
This presentation and slide set do not represent the policy of either the Agency for Healthcare Research and Quality (AHRQ) or the U.S. Department of Health and Human Services (DHHS).
The views expressed herein are those of the presenter, and no official endorsement by AHRQ or DHHS is intended or should be inferred.
Current information about the Patient Safety Program should be obtained from AHRQ, and not from these slides.

3. Speakers Deborah M. Nadzam, PhD Project Director, AHRQ KT/I Contract
Joint Commission Resources
Kim Visconti, RN
Discharge Advocate
Boston Medical Center

4. Today’s Web Conference
Objectives of AHRQ-funded Knowledge Transfer project - Deborah Nadzam
Project RED – 11 steps to an improved patient discharge process
Kim Visconti
The value proposition of Project RED
Deborah Nadzam
How to participate in this project

5. AHRQ-funded Knowledge Transfer Project
Background
Knowledge Transfer/Implementation contract
Task assignment: Project RED intervention
Secure and support participation by 50 hospitals

6. Project Expectations Secure executive sponsorship
Assign project team and project leader
Identify targeted population of patients*
Determine approach for generating After Hospital Care Plan (ACHP)*
Identify discharge advocate(s) and staff to make post-discharge phone calls
Participate in focus group conference call

7. Project Expectations cont’d
Participate in web conference training
Schedule bi-weekly consulting calls with assigned JCR consultant
Provide data to JCR re: readmission, ALOS, patient satisfaction, resource investments
Participate in all-site web conference discussions
Participate in case-study interviews

8. “Perfect Storm" of Patient Safety
39.5 million hospital discharges per year
$329.2 billion in total annual costs!
Hospital discharge is not-standardized and marked with poor quality.
Loose Ends
Communication
Poor Quality Info
Poor Preparation
Fragmentation
Great Variability
N summary – there is great room for improvement in the hospital discharge.
19% of patients have a post-discharge AE
20% of Medicare patients readmitted within 30 days
Only half had a visit in the 30 days after discharge1 8

9. More than Just Patient Safety
"Hospitals with high rates of readmission will be paid less if patients are readmitted to the hospital within the same 30-day period saving $26 billion over 10 years"
Obama Administration Budget Document
MedPAC recommends reducing payments to hospitals with high readmission rates MEDPAC Testimony before Congress March ‘09
CMS: 14 Quality Improvement Organizations “Safe Transitions” demonstration projects
CMS to release new payment scheme

10. Most Common Reasons for Avoidable Readmission are not Diagnosis-specific
Poor discharge instruction:
Poor patient understanding of how to use medications
Patient doesn’t learn warning signs to report to their physician
Poor transfer of information to ambulatory caregivers:
Hospital to nursing home staff
Hospital to primary care physician
Lack of clarity on end of life care preferences

11. Most Common Reasons for Avoidable Readmission cont’d
Lack of timely post-discharge physician visit:
Physician unaware of hospitalization
Patient has no primary care physician
Patient has no transportation to see primary care physician
Poor medication reconciliation yields duplication or interaction

12. Diagnosis-specific Reasons for Avoidable Readmissions
COPD, pneumonia—
Patients not getting home health benefits
Pneumonia readmissions may reflect need for end of life care
Cardiac care—
Cardiologists not arranging follow up for heart failure patients
Readmissions higher for heart failure patients with behavioral problems

13. Diagnosis-specific Reasons for Avoidable Readmissions cont’d
Post surgery—
Surgeons not arranging for post-surgical primary care.
Post-CABG patients, expecting to be pain free, seek readmission for angina
Inadequate teaching of the patient in caring for their body after surgery (e.g., incision care)
Dialysis patients very vulnerable to drug therapy changes

14. The ReEngineered Discharge Implementation Overview
Kimberly Visconti, RN Discharge Advocate Department of Family Medicine Boston University Medical Center

15. Principles of the Newly Re-Engineered Hospital Discharge
1) Explicit delineation of roles and responsibilities 2) Discharge process initiation upon admission 3) Patient education throughout hospitalization 4) Timely accurate information flow: From PCP ► Among Hospital team ► Back to PCP 5) Complete patient discharge summary prior to discharge 6) Comprehensive written discharge plan provided to patient prior to discharge 7) Discharge information in patient’s language and literacy level 8) Reinforcement of plan with patient after discharge 9) Availability of case management staff outside of limited daytime hours 10) Continuous quality improvement of discharge processes 15 15

16. RED Checklist Eleven mutually reinforcing components:
1. Medication reconciliation
2. Reconcile discharge 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. Discharge summary sent to PCP
11. Telephone reinforcement
Adopted by
National Quality Forum
as one of 30 US
"Safe Practices" (SP-15) 16 16

17. RED Component #1 Educate patient about their diagnosis throughout the hospital stay
The RED intervention starts within 24 hours of the patient’s admission to the hospital and continues daily until discharge
SP-15: “preparation for discharge occurring with documentation, throughout the hospitalization” 17 17

18. Make appointments for clinician follow-up and post-discharge testing
RED Component #2
Make appointments for clinician follow-up and post-discharge testing
Schedule PCP appointment within 2 weeks after discharge
Review the provider’s location, transportation and plan to get to appointment
Consult with patient regarding best day and time for appointments
Discuss reason for and importance of all follow-up appointments and testing
SP-15: “explicit delineation of roles and responsibilities in the discharge process” 18 18

19. RED Component #3 Discuss tests/studies completed and who will follow-up on results
Explain tests and studies done while in the hospital and tell the patient which clinician is responsible for reviewing the results
Encourage the patient to discuss tests his/her PCP; let the patient know that this information will be listed on the AHCP
SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge” 19 19

20. Red Component #4 Organize Post-discharge Services
Collaborate with case manager and social worker about patient needs and post-discharge services
Provide patient with contact information for these services (phone number, name of company, etc.)

21. RED Component #5 Confirm the Medication Plan
Reconcile the patient’s home medication list upon admission to the hospital
Review each medication; make sure that the patient knows why they take it
Discuss new medications each day with medical team and with patient
SP-15 “completion of discharge plan and discharge summaries before discharge” 21 21

22. RED Component #6 Reconcile discharge plan with National Guidelines
Communicate with medical team each day about the discharge plan
Recommend actions that should be taken for each patient under a given diagnosis 22

23. RED Component #7 Review appropriate steps for what to do if a problem arises
What constitutes an emergency
What to do if a non-emergent problem arises
Where to find contact information for the
discharge advocate and PCP on the After
Hospital Care Plan
SP-15 “The time from discharge to the first appointment with the accepting physician represents a period of high risk. All patients discharged from hospitals should be told what to do if a question or problem arises, including whom to contact and how to contact them. Guidance should also be provided about resources for patients’ questions once they are discharged.” 23 23

24. RED Component #8 Expedite transmission of the discharge summary to the PCP
Fax the discharge summary and AHCP to PCP within 24 hours after discharge
SP-15 “reliable information from the primary care physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods”
“A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.” 24 24

25. RED Component #9 Assess degree of understanding by asking patient to explain the details of the plan
Deliver information to reach those with low health literacy level
Include caregivers when appropriate
Utilize professional interpreters as needed
SP-15 "Before discharge, present a clear explanation that the patient understands that addresses post-discharge medications, how to take them and how and where prescription can be filled.  This information must also be communicated to the accepting physician.” 25 25

26. RED Component #10 Give the patient a written discharge plan at time of discharge
The AHCP should include:
1) Principal discharge diagnosis
2) Discharge medication instructions
3) Follow-up appointments with contact
information
4) Pending test results
5) Tests that require follow up
SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge” 26 26

27. After Hospital Care Plan

36. RED Component # 11 Provide telephone reinforcement of the discharge plan after discharge
Call patient within 72 hours after discharge
Assess patient status
Review medication plan
Review follow-up appointments
Take appropriate actions to resolve problems
SP-15 “Prospectively identify and provide a mechanism to contact patients with incomplete or complex discharge plans after discharge to assess the success of the discharge plan, address questions or issues that have arisen surrounding it, and reinforce its key components, in order to avoid post discharge adverse events and unnecessary re-hospitalizations"  36 36

37. 11 RED Components Enable Discharge Advocates to:
Prepare patients for hospital discharge
Help patients safely transition from hospital to home
Promote patient self-health management
Support patients after discharge through follow-up phone call 37

38. Challenges to Implementation: Medical Team Related
Busy medical team; discharge receives low priority in the work schedule of inpatient clinicians
Discharge is relegated to least experienced team member
Last minute test / consultations resulting in delay of final discharge plan and medication list
Inaccurate medication reconciliation
Discharge medication reconciliation started on the day of discharge 38 38

39. Challenges to Implementation: Hospital Related
Lack of resources and financial incentives to sustain discharge programs
Standardized discharge papers; not personalized or in language of patient
Resistance to change by clinicians
Financial pressure to fill beds as soon as they are empty 

40. Challenges to Implementation: Patient Related
Patient with no PCP
Limited or no insurance coverage
Inability to pay for medication co-pays
Long wait times calling health centers
Late discharge; less effective teaching to patients who are anxious to leave 40 40

41. Using Health IT to Overcome Challenge of RN Time
Potential in future to link to patient EMR so that information can flow into workstation
Assist in transferring clinical information between health care settings
Enhance patient education before discharge
Develop therapeutic alliance with patients
Help determine patient competency

42. Automated Discharge Workflow SP-15 “the development of IT systems to collect discharge information and create discharge plans from existing hospital databases could enable components of the plan to be easily collected”

43. Conclusions
RED is NQF Safe Practice
RED:
Can be delivered following the 11 components and using the ACHP tool
Can decrease hospital use
30% overall reduction
Savings of $412 per patient
Success through elimination of barriers
-- Coordination and change are challenging
-- Providers must collaborate and work together
Health IT could help
Improve delivery
Further improve cost savings and build the business case

44. Value Proposition Hospitals Improved HCAHPS scores
Potential reduction in malpractice claims
Prepared for changes to CMS reimbursement penalties for high readmission rates
Improved relationship with private insurers looking to contain costs
Improved nurse/provider time utilization
Demonstrated “Meaningful Use” under the HITECH Act, eligibility for Medicare bonuses
Improved relationship with PCPs 44

45. Value Proposition cont’d
Insurers
Direct cost savings from reduced hospital utilization ($412 per patient discharged)
Patient satisfaction
Improved long-term patient outcomes 45

46. Value Proposition cont’d
Providers
Improved nurse/provider time utilization
Demonstrated “Meaningful Use” under the HITECH Act
Additional revenue from Current Procedural Terminology (CPT) codes
Improved patient satisfaction

47. Value Proposition cont’d
Patients/Caregivers
Improved outcomes
Co-pays and premiums applied to more effective services
Enhanced autonomy and ability to direct care
Enhanced portability of personal health records

48. Value Proposition cont’d
Primary Care Physicians/Other Specialists
Improved utilization and show rates by patients
Improved transmission of information to better care for patient
Increased patient satisfaction

49. Ready for Project RED? Next Steps Secure leadership commitment
Identify targeted populations to begin
Determine approach for developing After Hospital Care Plan
Identify staff: Project Leader, Project Team, Discharge Advocate(s)

50. Identify Targeted Patient Population
Start small!
Approaches to consider
Specific patient care unit
Diagnostic group
Physician’s patient group
Combination of above
Also
English-speaking patients
Discharged home
Access to telephone

51. Generating the AHCP
“Manual” – use of template for discharge advocate (DA) to enter all required data
Provide template to your IT department and request that they integrate with existing systems
Purchase software and integrate it with your existing systems

52. To participate in JCR’s AHRQ-funded project focused on Project RED
Contact Deborah Nadzam