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:1-866-639-0744, no code needed

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

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.

“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

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

ResearchQuestions We 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 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

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

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)

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

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 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

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 *

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

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!

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?

Should all patients get RED? 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?

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)

Overall Usability Ease of Use Overall Satisfaction

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

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?

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

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

RED for Boston HealthNet

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

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

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

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 39

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 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

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

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??

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

Thank You! Questions suzanne.mitchell@bmc.org brian.jack@bmc.org Project RED Website http://www.bu.edu/fammed/projectred/

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

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