Project RED: Reengineering the Hospital Discharge Process (Text Version)

On September 15, 2009, Brian Jack MD made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (39 MB).

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Slide 1

 

Project RED: Reengineering the Hospital Discharge Process

AHRQ 2009 Conference
Research to Reform: Achieving Health System Change
September 13-16, 2009

Brian Jack MD
Associate Professor and Vice Chair
Department of Family Medicine
Boston University School of Medicine

Slide 2

 

Plan for Today

1. The Problem
2. How We Got Started
3. NQF 'Safe Practice'
4. Is 'Safe Practice' Safer?
5. Risk Factors for Rehospitalization
6. Barriers to Implementation
7. Roll-out
8. Can Health IT Deliver?

Slide 3

 

"Perfect Storm" of Patient Safety

The hospital discharge is non-standardized and frequently marked with poor quality.

In 2006, there were 39.5 million hospital discharges with costs totaling $329.2 billion!

Slide 4

 

Patients Are Not Prepared at Discharge

At Discharge:

• • 37% able to state the purpose of all their medications
  • 14% knew their medication's common side effects
  • 42% able to state their diagnosis

Patients' Understanding of Their Treatment Plans and Diagnosis at Discharge. Amgad N. Makaryus, MD, Eli A. Friedman, MD. Mayo Clinic Proceedings. August 2005; 80(8):991-994.

Slide 5

 

Little Time Spent on Discharge

• Audiotaped 97 discharge encounters
• 8 Elements—Roter Interactional Analysis
  • Nurse, Pharmacist, Physician, Nurse Case Manager
• Averaged 8 minutes (range, 2 to 28.5 min)
• No teachback 84% of the time
• Patient is a passive participant.
  • Two initiated questions
• Not comprehensive
  • 4 or fewer elements covered 50% of time

Slide 6

 

Pending Tests Not Followed

• 41% of inpatients discharged with a pending test result
• Over 9% potentially required action
• 2/3 of physicians unaware of results
• 37% actionable and 13% urgent

Image on top of slide titled" Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge" from Annals of Internal Medicine, 2005;143(2):121-8.

Slide 7

 

Work-ups Not Completed

• 25% of discharged patients require additional outpatient work-ups
• More than 1/3 not completed

Image of top of slide titled "Typing Up Loose Ends: Discharging Patients with Unresolved Medical Issues". Carlton Moore, MD, Thomas McGee, MD,MPH, Ethan Hahn, MD, MPH. Archives of Internal Medicine, 2007;167:1305-11.

Slide 8

 

Communication Barriers

Impact of patient communication problems on the risk of preventable adverse events in acute care settings.

Gillian Bartlett, PhD, Regis Blais, PhD, Robyn Tamblyn, PhD, Richard J. Clermont, MD and Brenda MacGibbon, PhD. CMAJ. June 2008;178(12)

• Patients with communication problems:
  • 3 times more likely to have adverse event
  • 46% had multiple adverse events

Slide 9

 

Communication Deficits at Hospital Discharge Are Common

Discharge summary not readily available:

• 12-34% at first post-discharge appt
• 51-77% at 4 weeks

Discharge summary lacking key components:

• Hospital course (7-22%)
• Discharge medications (2-40%)
• Completed test results (33-63%)
• Pending test results (65%)
• Follow-up plans (2-43%)

Direct communication, 3-20%

Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297(8):831-41.

Slide 10

 

Discharges are Variable by Day of the Week

Graph showing days to re-hospitalization.

Slide 11

 

Errors Lead to Adverse Events

Image: Annals of Internal Medicine article titled "The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital".

• 19% of patients had a post-discharge AE
• 1/3 preventable and 1/3 ameliorable

Image: Article titled "Adverse events among medical patients after discharge from hospital".

• 23% of patients had a post-discharge AE
  • 28% preventable and 22% ameliorable

Slide 12

 

A Real Discharge Instruction Sheet

Image: an example of an actual instruction sheet for a patient being discharges—how could anybody understand this?

Slide 13

 

"Perfect Storm" of Patient Safety

• The hospital discharge is non-standardized and frequently marked with poor quality.
  • Loose Ends
  • Communication
  • Poor Quality Info
  • Poor Preparation
  • Fragmentation
  • Great Variability
• 20% of Medicare patients readmitted within 30 days¹
• Only half had a visit in the 30 days after discharge¹

¹Jenks NEJM 2009.

Slide 14

 

Major Changes in Hospital Payments

• "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
• All cause readmission rates released this summer
• CMS: 14 Quality Improvement Organizations "Safe Transitions" demonstration projects
• AHA H2H—goal to reduce readmissions by 20% by 2012

Slide 15

 

Two Questions

We asked:

• Can improving the discharge process reduce adverse events and unplanned hospital utilization?

Grant reviewer asked:

• What is the "discharge process"?

Slide 16

 

Principles of the RED: Creating the Toolkit

Flow chart demonstrating the methods to carefully look at the process.

Slide 17

 

Process Mapping— Patient Education

Process flow chart showing Patient Preparation to Patient leaving the hospital bed.

Slide 18

 

Process Mapping—2 Discharge Summaries

Process flow chart for Patient Discharge procedures.

Slide 19

 

Re-Engineering the Discharge

• Iterative Group Process
• Identification of Potential Failures
• Prioritization
• Brainstorming of Alternatives
• Re-design of Process Map

Slide 20

 

Principles of the Newly Re-Engineered Hospital Discharge

1. Explicit delineation of roles and responsibilities
2. Patient education throughout hospitalization
3. Easy Information flow:
   > From PCP > Among hospital team > Back to PCP
4. Written discharge plan for patient
5. All information organized and delivered to PCP
6. Waiting until discharge order is written before beginning discharge process is error-prone
7. Efficient and safe hospital discharge is significantly more challenging if discharge personnel work only 7AM to 3 PM shift
8. All patients have access to their discharge information in their language and at their literacy level
9. Those at-risk have discharge plan re-enforced after discharge
10. Discharge processes benchmarked, measured and subject to continuous quality improvement programs

Slide 21

 

RED Checklist

Eleven 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
    • Telephone Reinforcement

Adopted by National Quality Forum as one of 30 "Safe Practices" (SP-11)

Slide 22

 

Should the NQF/RED be Done for Discharge at Every Hospital?

Hypotheses

A comprehensive discharge will:

• Lower hospital utilization
• Improve readiness for discharge
• Increase PCP follow-up

Slide 23

 

Methods— Randomized Controlled Trial

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)

Image of a flowchart showing:

Enrollment N=750→Randomization→RED Intervention N=375; Usual Care N=375→30-day Outcome Data; Telephone Call; EMR Review

Slide 24

 

After Hospital Care Plan

Image: Cover example for Maria Johnson
 

Slide 25

 

EACH DAY follow this schedule: Medication Schedule for Maria Johnson

Schedule chart for Maria Johnson.

Slide 26

 

Schedule chart for Maria Johnson with her Doctor contact information.

Slide 27

 

After Hospital Care Plan for Maria Johnson.

Slide 28

 

November 2005 Calendar showing Maria Johnson's medical appointments

Slide 29

 

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%)

* 3 subjects excluded from outcome analysis: subject request (n=2), died before index discharge (n=1)

Slide 30

 

Analysis

Primary outcome:

• Total hospital utilization (readmissions plus ED visits)
  • Intention-to-treat
  • Poisson tests for significance
  • Cumulative hazard curves generated for time to multiple events

Secondary outcomes:

• PCP follow-up rate, identified dc diagnosis, identified PCP name, self-reported preparedness for discharge, cost
  • Proportions tests for significance

Slide 31

 

What did we find?

Slide 32

 

Primary Outcome: Hospital Utilization within 30d after dc

	Usual Care (n=368)	Intervention (n=370)	P-value
Hospital Utilizations * Total # of visits Rae (visits/patient/month)	166 0.451	116 0.314	0.009
ED Visits Total # of visits Rate (visits/patient/month)	90 0.245	61 0.165	0.014
Readmissions Total # of visits Rate (visits/patient/month)	76 0.207	55 0.149	0.090

* Hospital utilization refers to ED + Readmissions

Slide 33

 

Cumulative Hazard Rate of Patients Experiencing Hospital Utilization
30 days After Index Discharge

Cumulative hazard curve—shows the cumulative hazard of hospital utilization over the 30 days after discharge from the index admission. For subjects with more than one event in that time period, all events were counted, with time-to-event measured from the date of index discharge for each one. The p-value, significant at 0.004, comes from a log-rank test, comparing the intervention subjects to control subjects.

Slide 34

 

Self-Perceived Readiness for Discharge (30 days post-discharge)

Bar graph showing measures of Prepared, Understand appts, Understand Meds, Understand Dx, and Questions answered between Usual Care and RED patients.

Slide 35

 

Outcome Cost Analysis

Cost (dollars)	Usual Care (n=368)	Intervention (n=370)	Difference
Hospital visits	412,544	268,942	+143,6022
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.

Slide 36

 

Medication Errors (MEs)

Collected at PharmD Telephone Call
2-4 days after discharge (n=197)

MEs due to failure to take medication at 2-4 days are shown in a table.

Slide 37

 

Medication Errors (MEs)
(PharmD Telephone Call)

MEs due to incorrect self-administration	No. (%)
Medication not on discharge summary	83 (45%)
Wrong frequency/interval	39 (21%)
Wrong dose	33 (18%)
Medication not on discharge summary, but in EMR	15 (8%)
Medication not in EMR, but on discharge summary	3 (2%)
Patient taking PRN instead of around-the-clock	2 (1%)
Other	10 (6%)
All subjects with MEs due to incorrect self-administration	87 (44%)

 

Slide 38

 

Medication Errors (MEs)
(PharmD Telephone Call)

MEs due to system error	No. (%)
Patients not given prescription for most current regimen on discharge	5 (29%)
Conflicting information	4 (24%)
Duplication on EMR medication list (same drug, same class, same indication)	3 (18%)
Patient does not know how to use device	2 (12%)
Patient has allergy/intolerance to medication	1 (6%)
Other	2 (12%)
Subjects with MEs due to system error	13 (7%)

Slide 39

 

Implications

The components of the RED should be provided to all patients as recommended by the National Quality Forum, Safe Practice #11.

Slide 40

 

For which subgroups is RED effective?

Slide 41

 

Health Literacy: Risk of hospital re-utilization

Bar graph showing percentage of health literacy in patients with levels of education from grades 3-9+.

Slide 42

 

Elderly: Outcomes For Ages ≥65yrs (121/738 Total Participants)
 

 

Slide 43

 

Depression: # Hospital Utilizations, Hospital Utilization Rate, and IRR at 30, 60 and 90 days

Hospital Utilization	Depression Screen *		p-value	IRR* (CI)
	Negative n=500 (68%)	Positive n=238 (32%)
No. of Hospital Utilizations† 30-day Hospital utilization rate	140 0.296	134 0.563	<0.001	1.90 (1.51, 2.40)
No. of Hospital Utilizations† 60-day Hospital utilization rate	231 0.463	205 0.868	<0.001	1.87 (1.55, 2.26)
No. of Hospital Utilizations† 90-day Hospital utilization rate	324 0.648	275 1.165	<0.001	1.79 (1.53, 2.10)

IRR = Incident Rate Ratio

*Depression screen determined by scoring of Patient Health Questionnaire-9 (PHQ9).

Depressive symptom score of 5 points or higher is designated as positive. (17)

†Number of hospital utilizations include all emergency department (ED) visits and hospital readmissions following discharge from Project RED index admission. ED visits leading to hospital admission are counted as one event. Sum reflects cumulative number of events over 30, 60 and 90 days.

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Gender: Primary outcomes &le:30 days after index hospitalization

	Males	Females	P value
Patients, n	367	370
Hospital utilizations, n (visits/patient/mo)*	174 (0.474)	108 (0.292)	<0.001
IRR (95% CI)	1.62 (1.28, 2.06)	REF
Emergency department visits, n (visits/patient/mo)	101 (0.275)	50 (0.135)	<0.001
IRR (95% CI)	2.04 (1.45, 2.86)	REF
Readmissions, n (visits/patient/mo)	73 (0.199)	58 (0.157)	0.09
IRR (95% CI)	1.27 (0.90, 1.79)	REF

Slide 45

 

Gender: Outcome data collected at 30-day follow-up call by gender

	Males	Females	P value
Able to identify PCP name	77%	88%	<0.001
How well did you understand your appointments after you left the hospital?	78%	87%	0.005
Visited PCP	49%	57%	0.04
Able to identify discharge diagnosis	73%	77%	0.24
How well did you understand how to take your medications after leaving the hospital?	84%	88%	0.12

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RED Effectiveness for Risk Stratified Groups

1. This graph shows that at the extremes (Risk Group 20 or lower or 70 and above) the intervention does not work. For groups 20 to 70 (mid-level risk), the intervention is very effective with the exception of a small significantly insignificant point.

2. The y axis is hospital reutilization rate, defined as TOTAL number of hospital readmissions + ER visits/person/30 days. This counts multiple admissions/ER visits per index discharge.

3. Risk factors included in the analysis are: gender, marital status, depression status, hypertension/diabetes/asthma status, "frequent flier"status, and homelessness Risk factors included in the analysis are: gender, marital status, depression status, hypertension/diabetes/asthma status, "frequent flier" status, and homelessness

Slide 47

 

Should hospitals use RED?

Slide 48

 

Why Hospitals Should Use RED

• Volume
  • Opens Beds by decreasing 30 day re-hospitalization/ED use by 30 percent
  • Improves PCP follow-up
• Satisfaction
  • Improves satisfaction of patients and their families
  • Improves community image
  • Brands the hospital with high quality
• Safety
  • National Quality Forum Safe Practice
  • Safe practice endorsed by IHI, Leapfrog, CMS, TJC
  • Exceeds Joint Commission standards
  • Improves patient "readiness for discharge"
  • Documents the discharge teaching and preparation
  • Documents patient understanding of the plan
• Cost —the business case
  • Saves $412 per subject enrolled
  • Allows physicians to bill higher discharge level
  • Reduces diversion and creates greater capacity for higher revenue patients
  • Improves relationships with ambulatory providers
  • Improves market share as "preferred provider"
  • * Prepares for change in CMS rules regarding readmission reimbursement

Slide 49

 

Dissemination

• Website diagnostics
  • Thousands of worldwide contacts
  • Downloads of AHCP and training manual
  • Hundreds of email contacts
• PR
  • AHRQ webinar—2,200 hospitals signed up
  • >15 national magazine stories
• AHRQ Roll -out
  • About 6 hospital beta sites across country
  • Studying the process of implementation and results
• Office of Tech Transfer at BU
  • US Business partner
  • 132 hospitals now actively engaged
  • Irish International Partner with 60,000 wired beds

Slide 50

 

Barriers to Implementation

• Not clear who is responsible for discharge
• Discharge receives low priority of inpatient clinicians
• Medications are not finalized until late in the hospitalization
• Financial pressure to fill beds as soon as they are empty
• Medication reconciliation with the ambulatory electronic health record is often not done
• Discharge is relegated to least experienced team members
• Discharges often occur in the late in the day when optimal staffing not available
• Doing things differently (changing culture) takes lots of time and effort
• Adding more to already overworked nurses won't work

Slide 51

 

Can Health IT assist with providing a comprehensive discharge?

Slide 52

 

Using Health IT to Overcome Challenge of RN Time

Embodied Conversational Agents

• Emulate face-to-face communication
• Develop therapeutic alliance
• Empathy, gaze, posture, gesture
• Teach RED
• Determine Competency
• Can drill down
• Maps of CHCs
• High Risk Meds
  • Lovenox
  • Insulin
  • Prednisone taper

Slide 53

 

Studies of Nurse-Patient Interaction

Image: Image of a nurse pointing to a patient daily medication chart.

Slide 54

 

Workstation for Data Entry

Image of a sample workstation web site.

Slide 55

 

Automated Discharge Workflow

Image: Flowchart of discharge work.

• Patient information entered into workstation
• Paper booklet generated and reviewed
• Booklet images, indexes, and patient health information downloaded to the kiosk
• Patient—VN interaction
• Issues displayed for nurse follow-up

Slide 56

 

Patient Interacting with Louise

Image: Patient laying in hospital bed reviewing medical documentation with Louise, the virtual nurse.

Slide 57

 

Embodied Conversational Agent (http://relationalagents.com/red_demo_4545.wmv>)

Slide 58

 

Pilot Study: Self-Report Ratings of the Virtual Nurse (mean (SD))

Image: table results from a questionnaire regarding Louise' usefulness.

Slide 59

 

Image: menu selections prompting user to indicate how they are feeling.

Slide 60

 

Who Would You Rather Receive Discharge Instructions From?

Image of a piechart. 

Results: Agent: 74%; Either: 16%; Nurse: 10%.

"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."

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Agents Could Be More Effective Than People

1. Relies minimally on text
2. Enhances recall
3. Provides redundant channels of information
4. Listeners pay attention to gestures
5. More flexible and effective than a videotaped lecture
6. Individualized, consistent messages, every time
7. Cost effective - less need for clinician time
8. Easy-to-use
9. No time limit
10. Can assess competency and understanding
11. Can adapt to address issues of race, gender, ethnicity
12. Enhance learning

Slide 62

 

Current Work Ambulatory Safety and Quality (ASQ)

• Post-discharge web-based system designed to emulate the post-hospital phone call
• Will have multiple interactions in the days between discharge and first PCP appointment
• Designed to
  • Enhance adherence
  • Monitor for adverse events
  • Prevent adverse events
    • Identifying post-dc "confusion" and rectify
    • Screening system for who needs 2 day phone call
• Beginning a trial of this system

Slide 63

 

Conclusions

• Hospital Discharge is low hanging fruit for improvement
• RED is NQF Safe Practice
• RED:
  • Can be delivered using AHCP tool
  • Can decreased hospital use
    • 30% overall reduction
    • NNT = 7.3
    • Saves $412 per patient
• Health IT Could Help
  • could improve delivery
  • further improve cost savings and build the business case

Slide 64

 

Thank you!

Contacts

Project RED Website
http://www.bu.edu/fammed/projectred/

Engineered Care Website
info@engineeredcare.com

Slide 65

 

Image: Louise cover screen

Slide 66

 

Image: Louise Medications screen

Slide 67

 

Image: Louise Diagnosis screen

Slide 68

 

Image: Louise Closing screen