Testing the Re-Engineered Discharge: Hands-on Health Literacy (Text Version)

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, Brian Jack, M.D., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (2.1 MB; Plugin Software Help).

Slide 1

Testing the Re-Engineered Discharge (RED)

Hands-on Health Literacy
September 9, 2008

Principal Investigator: Brian Jack, MD
Associate Professor and Vice Chair

Department of Family Medicine
Boston Medical Center /
Boston University School of Medicine

Slide 2

"Perfect Storm" of Patient Safety

• Loose Ends—workups NOT completed.
• Communication—DC [discharge] summary not available.
• Poor Quality Info—DC summary lack results.
• Poor Preparation—few pts know meds/dx.
• Fragmentation—who is in charge?

Slide 3

Principles of the RED: Creating the Toolkit

Screen shot of a chart that shows:

• Readmission Within 6 Months
• Between Readmission Within 6 Months and Hospital Discharge:
  • Upward arrow with text box underneath stating Probabilistic Risk Assessment
• Hospital Discharge
• Upward arrow from the text box Process Mapping pointing to Hospital Discharge.
• Between Hospital Discharge and Patient Readmitted Within 3 Months:
  • Failure Mode and Effects Analysis
• Patient Readmitted Within 3 Months
• Qualitative Analysis and upward arrow.
• Root Cause Analysis and upward arrow.

Slide 4

RED Checklist

Eleven mutually reinforcing components:

1. Medication Reconciliation.
2. Reconcile Plan with National Guidelines.
3. Follow-up Appointments.
4. Outstanding Tests and Studies.
5. Post-discharge Services.
6. Written discharge plan.
7. What to do if a problem arises.
8. Patient Education.
9. Assess patient understanding.
10. Dc summary to Primary Care Physician (PCP):
    >Telephone Reinforcement.

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

Slide 5

The slide shows a sample cover of an "After Hospital Care Plan" for a discharged patient from Boston Medical Center.

Slide 6

The slide shows a sample page from the "After Hospital Care Plan" entitled "Medicines." It shows the name of the medicine, dosage, what it is for, and what time of day to take it.

Slide 7

The slide shows a continuation of the previous slide"s sample page, "Medicines."

Slide 8

The slide shows a sample calendar from the plan which highlights when the patient left the hospital, when the pharmacist will call, and when future appointments are scheduled.

Slide 9

The slide shows a sample page from the plan which gives information on "Noncardiac Chest Pain."

Slide 10

Intervention to Administer RED

• In Hospital—Discharge Advocate (DA):
  • Nurse.
  • Interact with care team—med rec and guidelines.
  • Prepare the After Hospital Discharge Plan (AHCP).
  • Teach the AHCP.
• After Discharge—Clinical Pharmacist:
  • Follow-up call @ 2-3 days.
• The DA and Pharm manual:
  • Scripts for each task.

Note: The slide shows a photograph of a woman.

Slide 11

Testing the RED Schematic

Screen show of a flowchart showing:

• Enrollment N=750
• Informed Consent
• Randomization
• RED Intervention and Usual Care
• 30 Day Outcome Data; Telephone Call; Chart Review

Slide 12

AHCP Evaluation: 30 days post-discharge

The pie chart presents the results to the question, "How useful was the booklet to you?"

• Extremely: 19%
• Very: 39%
• Moderately: 21%
• A little bit: 17%
• Not at all: 4%

Slide 13

AHCP Evaluation: 30 days post-discharge (continued)

The pie chart presents the results to the question, "What was the most helpful part of the booklet?"

• Medical Provider Information: 13%
• RED Medication Schedule: 25%
• Appointment Page: 20%
• Appointment Calendar: 12%
• Diagnosis Information: 15%
• Other: 15%

Slide 14

AHCP Evaluation: 30 days post-discharge (continued)

The pie chart presents the results to the question, "How helpful was the RED medication calendar?"

• Extremely: 26%
• Quite a bit: 45%
• Moderately: 15%
• A little bit: 9%
• Not at all: 4%

Slide 15

Self-Perceived Readiness for Discharge
30 days post-discharge

The bar graph shows RED had higher numbers than Usual Care in the following areas:

• Prepared
• Understand Appointments
• Understand Meds
• Understand Dx
• Questions answered

Slide 16

Primary Outcome

Slide 17

Cumulative Hazard of Patients Experiencing a Hospital Utilization in 30d After Index Discharge

Screen shot of a line graph presenting the "Probability of Survival" for 0 to 30 days after discharge for RED and Usual Care. The results show the probability of survival declining for both RED and Usual Care as time elapses. However, at 10 days after discharge, RED's decline is not as rapid as Usual Care.

Slide 18

Conclusions from the Randomized Controlled Trial (RCT)

RED:

• Successfully delivered using:
  • RED protocols.
  • AHCP.
• Improves "Readiness for Discharge".
• Decreases hospital use:
  • 32% reduction.
  • Number needed to treat (NNT) = 7.9.
• Helps high hospital utilizers:
  • 35% reduction.
• Is Cost-Effective:
  • $329/patient.
  • 38 million discharges @ $753 billion x 32% eligible = 4 billion.

Slide 19

Major Problem: RN Time Can Health Information Technology (IT) Help?

• Embodied Conversational Agent to Teach the AHCP:
  • Emulate face to face communication.
  • Develop therapeutic alliance:
    • Empathy.
    • Gaze, posture, gesture.
• Workstation database to automatically print AHCP and "feed" Louise.
• Connect hospital IT to workstation.
• Kiosk for patient access.

Note: The slide shows an image of a woman named "Louise".

Slide 20

The slide shows a photograph of a woman in a hospital bed adjusting a telemedicine screen.

Slide 21

Social Chat

Slide 22

Cover

Slide 23

Medications

Slide 24

Appointments

Slide 25

Diagnosis

Slide 26

Closing

Slide 27

Thank You AHRQ!

• PI: Brian Jack, MD
• Michael Paasche-Orlow MD, MPH
• Caroline Hesko, MPH
• Irina Kushnir
• Fiana Gershengorina
• Kim Visconti, RN
• Jared Kutzin, RN, MPH
• Alison Simas, RN
• Mary Goodwin, RN
• Lynn Schipelliti, RN
• Lindsey Hollister
• Maggie Jack
• Kacie Fyrberg, RN
• Vimal Jhaveri
• Laura Pfeifer
• Juan Fernandez
• David Anthony, MD, MSc
• Tim Bickmore PhD
• Gail Burniske, PharmD
• Kevin Casey, MPH
• VK Chetty, PhD
• Allyson Correia, RN
• Larry Culpepper, MD, MPH
• Shaula Forsythe, MPH, MS
• Rob Friedman, MD
• Jeffrey Greenwald, MD
• Anna Johnson
• Anand Kartha, MD
• Christopher Manasseh, MD
• Julie O'Donnell