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). Plugin Software Help.

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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

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Plan for Today

• The Problem
• How We Got Started
• NQF 'Safe Practice'
• Is 'Safe Practice' Safer?
• Risk Factors for Rehospitalization
• Barriers to Implementation
• Roll-out
• Can Health IT Deliver?

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"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!

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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.

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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

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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

Annals of Internal Medicine. 2005; 143(2):121-8.

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Work-ups Not Completed

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

Archives of Internal Medicine. 2007;167:1305-11.

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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

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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.

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Discharges are Variable by Day of the Week

Graph showing days to re-hospitalization.

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Errors Lead to Adverse Events

Image: Annals of Internal Medicine article. The incidence of 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

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A Real Discharge Instruction Sheet

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

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"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

Jenks NEJM 2009.

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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

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Two Questions

We asked:

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

Grant reviewer asked:

• What is the "discharge process"?

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Principles of the RED: Creating the Toolkit

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

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Process Mapping— Patient Education

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

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Process Mapping—2 Discharge Summaries

Process flow chart for Patient Discharge procedures.

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Re-Engineering the Discharge

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

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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

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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)

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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

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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)

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After Hospital Care Plan

Image: Cover example for Maria Johnson

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EACH DAY follow this schedule: Medication Schedule for Maria Johnson

Schedule chart for Maria Johnson.

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Schedule chart for Maria Johnson with her Doctor contact information.

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After Hospital Care Plan for Maria Johnson.

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November 2005 Calendar showing Maria Johnson's medical appointments

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How well did we deliver intervention

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

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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

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What did we find?

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Primary Outcome: Hospital Utilization within 30d after dc

* Hospital utilization refers to ED + Readmissions

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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.

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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.

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Outcome Cost Analysis

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

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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 here.

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Medication Errors (MEs)
(PharmD Telephone Call)

MAEs due to incorrect administration are shown here

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Medication Errors (MEs)
(PharmD Telephone Call)

And those due to system error are shown here

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Implications

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

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For which subgroups is RED effective?

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HEALTH LITERACY: Risk of hospital re-utilization

Bar graph showing health literacy in grades 3-9+.

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

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

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 =30 days after index hospitalization

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

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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
 

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Should hospitals use RED?

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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

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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

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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

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Can Health IT assist with providing a comprehensive discharge?

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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

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Studies of Nurse-Patient Interaction

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

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Workstation for Data Entry

Image: The workstation is where data about discharge plan is entered to feed the AHCP and Louise

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Automated Discharge Workflow

Image: Discharge work showing

• 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

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Patient Interacting with Louise

Image: Patient laying in hospital bed reviewing medical documentation with Louise.

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Embodied Conversational Agent http://relationalagents.com/red_demo_4545.wmv (Plugin Software Help)

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

Image: questionnaire regarding Louise' usefulness.

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

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Who Would You Rather Receive Discharge Instructions From?

"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

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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

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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

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Thank you!

Contacts

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

Engineered Care Website
info@engineeredcare.com

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Image: Louise cover screen

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Image: Louise Medications screen

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Image: Louise Diagnosis screen

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Image: Louise Closing screen