Project RED: The ReEngineered Discharge (Text Version)
Project RED: The ReEngineered Discharge
Care Transitions: Navigating the Health Care System
AHRQ 2011 Annual Scientific Meeting
September 19, 2011
Brian Jack MD
Professor and Vice Chair
Department of Family Medicine /
Boston University School of Medicine
Agenda for Today
- Opportunities for improved transitions.
- Policy implications.
- RED checklist.
- Evidence for RED.
- New AHRQ Toolkit.
- Challenges to Implementation.
"Perfect Storm" of Patient Safety
- 39.5 million hospital discharges per year.
- Costs totaling $329.2 billion!
- Hospital discharge is not-standardized:
- Loose Ends.
- Poor Information.
- Poor Preparation.
- Great Variability.
- 19% of patients have a post-discharge adverse events (AE).
- 20% of Medicare patients readmitted within 30 days.
A Real Discharge Instruction Sheet
Image: A filled out discharge instruction form is shown.
Patient Safety Has Collided with Policy
- MedPAC (March '09):
- Recommends reducing payments to hospitals with high readmission rates.
- "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".
- Patient Protection and Affordable Care Act (2010):
- Accountable Care Organizations → begin 1/1/2012.
- Expanding Authority to Bundle Payments and Value-Based Purchasing:
- Myocardial infarction (MI), congestive heart failure (CHF), pneumonia (PNA) → "Starter Set".
- Payments changes for discharges beginning October 1, 2012.
National Programmatic Activity in Transitions
- Centers for Medicare & Medicaid Services (CMS):
- Quality Improvement Organizations (QIOs):
- 9th Scope of Work—focused demonstrations in Safe Transitions.
- Impressive results implementing transitional care interventions.
- Now expanded to 50 states.
- Partnership for Patients Program:
- 100 Hospital Engagement Contractors funded to implement 10 evidence based solutions to decrease AEs.
- Community Based Care Transitions Program (CCTP or 3026):
- New payment policies to encourage improved transitions.
- Hospitals, Providers, Community-based organizations.
- Quality Improvement Organizations (QIOs):
- Office of the National Coordinator for Health Information Technology (Health IT):
- Beacon Communities.
- Focus on Health IT in bringing transitional care interventions to scale.
- Public Sector:
- Many BIG and small fish—most Health IT.
- "Transitions" morphing into "care of complex patients".
Principles of the RED: Creating the Toolkit
Image: A flowchart showing the process of hospital discharge and patient readmission.
Eleven 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.
Adopted by National Quality Forum as one of 30 "Safe Practice" (SP-11).
Methods—Randomized Controlled Trial
Image: A flowchart: Enrollment N=750 → Randomization → RED Intervention N=375 and Usual Care N=375 → 30-day Outcome Data: Telephone Call and Electronic Medical Record (EMR) Review.
- 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).
Personalized Cover Page
Image: A sample cover page for an after hospital care plan.
Updated List of All Medicines
Image: A sample medication list with dosages and schedule.
Medication Page (2 of 3)
Image: Page 2 of a sample medication list with dosages and schedule.
Image: A sample appointments page.
Image: A sample appointment calendar.
Primary Diagnosis Page
Image: A brochure on congestive heart failure.
Primary Outcome: Hospital Utilization Within 30d After Dc
|Hospital Utilizations *|
Total # of visits
Total # of visits
Total # of visits
* Hospital utilization refers to ED + Readmissions.
Cumulative Hazard Rate of Patients Experiencing Hospital Utilization 30 days After Index Discharge
Image: A chart labeled "Cumulative Hazard Rate of Patients Experiencing Hospital Utilization 30 days After Index Discharge (days)" is shown. If there is intervention there is a decrease in hospital utilization.
Outcome Cost Analysis
|Cost (dollars)||Usual Care|
We saved $412 in outcome costs for each patient given RED.
Consultations to Implementers
- National Quality Forum (NQF) .
- Joint Commission.
- American Medical Association (AMA).
- Department of Veterans Affairs (VA).
- State Hospital Associations.
- American Hospital Association (AHA)—Hospital to Home (H2H).
- Institute for Healthcare Improvement (IHI) / Commonwealth Fund—STARS.
- Society Hospital Medicine—BOOST.
- National Association of Public Hospitals and Health Systems (NAPH).
- Many Health Plans.
- Private Companies.
- AHRQ Webinar in 2009—2,200 hospitals.
- Web site diagnostics—28,530 hits in last 12 months.
- Direct Hospital "Reverse Detailing" of Best Practices.
- Contract to JCR to implement at 50 Hospitals, renewed for 250 more.
AHRQ Contract to Study Dissemination
- Overview of the Toolkit. Why is this Important?
- How to Begin Implementation at Your Hospital.
- How to Deliver RED.
- How to Conduct a Post-discharge Follow-up Phone Call.
- How To Benchmark Your Improvement Process.
- How to Deliver RED to Diverse Populations.
10 hospital beta sites across country:
- Does RED work in the real world?
- What works? What doesn't? What are the barriers?
- How to Adapt RED for diverse populations.
Barriers to High Quality Transitions
- Lack of resources.
- "Heads on Beds".
- Delayed discharge.
- Discharge receives low priority.
- Last minute test / consultations.
- Communication with PCP is low priority.
- Language and health literacy issues.
- Substance abuse/depression.
Barriers to RED
- Who serves as the Discharge Educator?
- Who does the 2 day phone call?
- How is the AHCP produced?
- Can dc summaries be done in 1-2 days?
- Who does med rec?
- Can appointments be made?
Role of Senior Leadership
- Align with organization's strategies & priorities.
- Set the vision and the goal.
- Communicate Commitment:
- Newsletter, grand rounds, M+M, RCA, E-mails.
- Provide resources & staff.
- Create implementation team.
- Set policies to integrate across organizational boundaries.
- Get IT on board.
- Hold people accountable.
- Recognize and reward success.
Role of Implementation Team
- Recruit a collaborative, interdisciplinary team.
- Identify process owners and change champions.
- Staff Engagement:
- Energize staff.
- Get buy-in.
- Build skills to support and sustain improvement.
- Trouble shoot as RED is rolled out.
- Monitor progress to provide feedback.
- Monitor sustainability.
Changing the Culture of Hospitals is Hard
"Culture Eats Strategy for Lunch"
Image of staff involved in Project RED.
How to Get Started
- Step 1: Make a clear and decisive statement and get buy in.
- Step 2: Appoint team leader.
- Step 3: Constitute implementation team.
- Step 4: Analyze current discharge process and rehospitalization rate.
How to Get Started—2
- Step 5: Establish goals. What is the target rehospitalization rate?
- Step 6: Establish timeline.
- Step 7: Identify the target patient population.
- Step 8: Decide how to fulfill the role of discharge educator.
- Step 9: Identify approach for follow up phone calls.
How to Get Started—3
- Step 10: Determine how to train DE & phone call staff.
- Step 11: Decide how to generate 'AHCP'.
- Step 12: Adapt transitions of care for low health literacy and LEP patients.
- Step 13: Decide How and What to Measure.
- Step 14: Monitor and Feedback Process and Outcome Measures.
Using Health IT to Overcome Challenge of RN Time
- Embodied Conversational Agents:
- Emulate face-to-face communication.
- Develop therapeutic alliance using empathy, gaze, posture, gesture.
- Teach RED.
- Determine Competency.
- Can drill down.
- Maps of CHCs.
- High Risk Meds:
- Prednisone taper.
Image: To the right of the text is a drawing of two nurses named "Louise" and "Elizabeth".
Patient Interacting with Louise
Image: A patient interacting with the virtual nurse "Louise" is shown.
Who Would You Rather Receive Discharge Instructions From?
36% prefer agent.
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."
Image: A bar chart showing preferences. Mean = 4.28, Std. Dev. = 2.008, N = 143.
Image: A group of people including AHRQ Director Dr. Carolyn Clancy and HHS Secretary Kathleen Sebelius.
Patient Activation Page
Image: A sample questions form for patients.
The Importance of Organizational Context
- Support of senior leader.
- Implementation team that engages frontline staff.
- Redesign work processes.
- Monitored progress.