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

Slide presentation from the AHRQ 2009 conference

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


Slide 1

 Slide 1. Project RED: Reengineering the Hospital Discharge Process

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

 Slide 2. Plan for Today

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

 Slide 3. Perfect Storm of Patient Safety

"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

 Slide 4. Patients Are Not Prepared at Discharge

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

 Slide 5. Little Time Spent on Discharge

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

 Slide 6. Pending Tests Not Followed

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

 Slide 7. Work-ups Not Completed

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

 Slide 8. Communication Barriers

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

 Slide 9. Communication Deficits at Hospital Discharge Are Common

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

 Slide 10. Discharges are Variable by Day of the Week

Discharges are Variable by Day of the Week

Graph showing days to re-hospitalization.

Slide 11

 Slide 11. Errors Lead to Adverse Events

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

Slide 12. A Real Discharge Instruction Sheet  

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

 Slide 13. Perfect Storm of Patient Safety

"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

Slide 14. Major Changes in Hospital Payments  

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

Slide 15. Two Questions  

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

 Slide 16. Principles of the RED: Creating the Toolkit

Principles of the RED: Creating the Toolkit

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

Slide 17

 Slide 17. Process Mapping- Patient Education

Process Mapping— Patient Education

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

Slide 18

 Slide 18. Process Mapping-2 Discharge Summaries

Process Mapping—2 Discharge Summaries

Process flow chart for Patient Discharge procedures.

Slide 19

 Slide 19. Re-Engineering the Discharge

Re-Engineering the Discharge

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

Slide 20

 Slide 20. Principles of the Newly Re-Engineered Hospital Discharge

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

 Slide 21. RED Checklist

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

 Slide 22. Should the NQF/RED be Done for Discharge at Every Hospital?

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

Slide 23. Methods- Randomized Controlled Trial  

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

 Slide 24. After Hospital Care Plan

After Hospital Care Plan

Image: Cover example for Maria Johnson
 

Slide 25

 Slide 25. Image of a Schedule chart for Maria Johnson

EACH DAY follow this schedule: Medication Schedule for Maria Johnson

Schedule chart for Maria Johnson.

Slide 26

 Slide 26. Image of a Schedule chart for Maria Johnson with her Doctor Contact  information

Schedule chart for Maria Johnson with her Doctor contact information.

Slide 27

Slide 27. Image of an After Hospital Care Plan for Maria Johnson.  

After Hospital Care Plan for Maria Johnson.

Slide 28

 Slide 28. Image of a November 2005 Calendar showing Maria Johnson's medical appointments

November 2005 Calendar showing Maria Johnson's medical appointments

Slide 29

 Slide 29. How well did we deliver intervention

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%)

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

Slide 30

 Slide 30. Analysis

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

 Slide 31. What did we find?

What did we find?

Slide 32

 Slide 32. Primary Outcome: Hospital Utilization within 30d after dc

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

 Slide 33. Cumulative Hazard Rate of Patients Experiencing Hospital Utilization: 30 days After Index Discharge

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

Slide 34. Self-Perceived Readiness for Discharge (30 days post-discharge)  

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

 Slide 35. Outcome Cost Analysis

Outcome Cost Analysis

Cost (dollars)Usual Care
(n=368)
Intervention
(n=370)
Difference
Hospital visits412,544268,942+143,6022
ED visits21,38911,285+10,104
PCP visits8,90612,617-3,711
Total cost/group442,839292,844+149,995
Total cost/subject1,203791+412

We saved $412 in outcome costs for each patient given RED.

Slide 36

 Slide 36. Medication Errors (MEs)

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

 Slide 37. Medication Errors (MEs) (PharmD Telephone Call)

Medication Errors (MEs)
(PharmD Telephone Call)

MEs due to incorrect self-administrationNo. (%)
Medication not on discharge summary83 (45%)
Wrong frequency/interval39 (21%)
Wrong dose33 (18%)
Medication not on discharge summary, but in EMR15 (8%)
Medication not in EMR, but on discharge summary3 (2%)
Patient taking PRN instead of around-the-clock2 (1%)
Other10 (6%)
All subjects with MEs due to incorrect self-administration87 (44%)

 

Slide 38

 Slide 38. Medication Errors (MEs) (PharmD Telephone Call)

Medication Errors (MEs)
(PharmD Telephone Call)

MEs due to system errorNo. (%)
Patients not given prescription for most current regimen on discharge5 (29%)
Conflicting information4 (24%)
Duplication on EMR medication list (same drug, same class, same indication)3 (18%)
Patient does not know how to use device2 (12%)
Patient has allergy/intolerance to medication1 (6%)
Other2 (12%)
Subjects with MEs due to system error13 (7%)

Slide 39

Slide 39. Implications  

Implications

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

Slide 40

 Slide 40. For which subgroups is RED effective?

For which subgroups is RED effective?

Slide 41

 Slide 41. HEALTH LITERACY: Risk of hospital re-utilization

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

 Slide 42. Elderly

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

 

Slide 43

 Slide 43. Depression

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

Hospital UtilizationDepression Screen *p-valueIRR*
(CI)
Negative n=500 (68%)Positive n=238 (32%)
No. of Hospital Utilizations
30-day Hospital utilization rate
140
0.296
134
0.563
<0.0011.90
(1.51, 2.40)
No. of Hospital Utilizations
60-day Hospital utilization rate
231
0.463
205
0.868
<0.0011.87
(1.55, 2.26)
No. of Hospital Utilizations
90-day Hospital utilization rate
324
0.648
275
1.165
<0.0011.79
(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.

Slide 44

 Slide 44. GENDER: Primary outcomes

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

 MalesFemalesP value
Patients, n367370 
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

 Slide 45. GENDER: Outcome data collected at 30-day follow-up call by gender

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

 MalesFemalesP value
Able to identify PCP name77%88%<0.001
How well did you understand your appointments after you left the hospital?78%87%0.005
Visited PCP49%57%0.04
    
Able to identify discharge diagnosis73%77%0.24
How well did you understand how to take your medications after leaving the hospital?84%88%0.12

Slide 46

 Slide 46. RED Effectiveness for Risk Stratified Groups

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

Slide 47. Should hospitals use RED?  

Should hospitals use RED?

Slide 48

 Slide 48. Why Hospitals Should Use RED

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

Slide 49. Dissemination  

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

 Slide 50. Barriers to Implementation

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

 Slide 51. Can Health IT assist with providing a comprehensive discharge?

Can Health IT assist with providing a comprehensive discharge?

Slide 52

 Slide 52. Using Health IT to Overcome Challenge of RN Time

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

 Slide 53. Studies of Nurse-Patient Interaction

Studies of Nurse-Patient Interaction

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

Slide 54

 Slide 54. Workstation for Data Entry

Workstation for Data Entry

Image of a sample workstation web site.

Slide 55

Slide 55. Automated Discharge Workflow  

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

 Slide 56. Patient Interacting with Louise

Patient Interacting with Louise

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

Slide 57

Slide 57. Embodied Conversational Agent  

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

Slide 58

Slide 58. Pilot Study: Self-Report Ratings of the Virtual Nurse (mean (SD))  

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

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

Slide 59

 Slide 59. An image of menu selections prompting user to indicate how they are feeling.

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

Slide 60

 Slide 60. Who Would You Rather Receive Discharge Instructions From?

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."

Slide 61

 Slide 61. Agents Could Be More Effective Than People

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

 Slide 62. Current Work Ambulatory Safety and Quality (ASQ)

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

 Slide 63. Conclusions

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

 Slide 64. Thank you!

Thank you!

Contacts

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

Engineered Care Website
info@engineeredcare.com

Slide 65

 Slide 65. An image of the Louise Cover screen

Image: Louise cover screen

Slide 66

 Slide 66. An image of the Louise Medications screen

Image: Louise Medications screen

Slide 67

Slide 67. An image of the Louise Diagnosis screen  

Image: Louise Diagnosis screen

Slide 68

 Slide 68. An image of the Louise Closing screen

Image: Louise Closing screen

Current as of December 2009
Internet Citation: Project RED: Reengineering the Hospital Discharge Process (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/jack/index.html