Project RED The Re-Engineered Discharge

JCR’s AHRQ-funded Project

April 2010

Disclaimer

This presentation and slide set do not represent the policy of either the Agency for Healthcare Research and Quality (AHRQ) or the U.S. Department of Health and Human Services (DHHS).

The views expressed herein are those of the presenter, and no official endorsement by AHRQ or DHHS is intended or should be inferred.

Current information about the Patient Safety Program should be obtained from AHRQ, and not from these slides.

Speakers

Deborah M. Nadzam, PhDProject Director, AHRQ KT/I ContractJoint Commission Resources Kim Visconti, RN Discharge AdvocateBoston Medical Center

Today’s Web Conference

Objectives of AHRQ-funded Knowledge Transfer project - Deborah Nadzam

Project RED – 11 steps to an improved patient discharge process Kim Visconti

The value proposition of Project RED Deborah Nadzam

How to participate in this project Deborah Nadzam

AHRQ-funded Knowledge Transfer Project

Background– Knowledge Transfer/Implementation

contract

Task assignment: Project RED intervention

Secure and support participation by 50 hospitals

Project Expectations

Secure executive sponsorship Assign project team and project leader Identify targeted population of patients* Determine approach for generating After

Hospital Care Plan (ACHP)* Identify discharge advocate(s) and staff

to make post-discharge phone calls Participate in focus group conference call

Project Expectations cont’d

Participate in web conference training Schedule bi-weekly consulting calls with

assigned JCR consultant Provide data to JCR re: readmission,

ALOS, patient satisfaction, resource investments

Participate in all-site web conference discussions

Participate in case-study interviews

“Perfect Storm" of Patient Safety

Loose Ends Communication Poor Quality Info Poor Preparation Fragmentation Great Variability

• 19% of patients have a post-discharge AE19% of patients have a post-discharge AE• 20% of Medicare patients readmitted within 30 days20% of Medicare patients readmitted within 30 days

• Only half had a visit in the 30 days after dischargeOnly half had a visit in the 30 days after discharge1

• 39.5 million hospital discharges per year39.5 million hospital discharges per year• $329.2 billion in total annual costs!$329.2 billion in total annual costs!• Hospital discharge is not-standardized and marked with poor Hospital discharge is not-standardized and marked with poor

quality.quality.

More than Just Patient Safety

"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 CMS: 14 Quality Improvement Organizations “Safe

Transitions” demonstration projects

CMS to release new payment scheme

http://www.hospitalcompare.hhs.gov/

Most Common Reasons for Avoidable Readmission are not

Diagnosis-specific

Poor discharge instruction: Poor patient understanding of how to use

medications Patient doesn’t learn warning signs to report

to their physician Poor transfer of information to ambulatory

caregivers: Hospital to nursing home staff Hospital to primary care physician Lack of clarity on end of life care preferences

Most Common Reasons for Avoidable Readmission cont’d

Lack of timely post-discharge physician visit: Physician unaware of hospitalization Patient has no primary care physician Patient has no transportation to see primary

care physician Poor medication reconciliation yields duplication

or interaction

Diagnosis-specific Reasons for Avoidable Readmissions

COPD, pneumonia— Patients not getting home health benefits Pneumonia readmissions may reflect need

for end of life care Cardiac care—

Cardiologists not arranging follow up for heart failure patients

Readmissions higher for heart failure patients with behavioral problems

Diagnosis-specific Reasons for Avoidable Readmissions cont’d

Post surgery— Surgeons not arranging for post-surgical

primary care. Post-CABG patients, expecting to be pain

free, seek readmission for angina Inadequate teaching of the patient in caring

for their body after surgery (e.g., incision care)

Dialysis patients very vulnerable to drug therapy changes

Kimberly Visconti, RN

Discharge AdvocateDepartment of Family Medicine

Boston University Medical Center

The ReEngineered DischargeThe ReEngineered Discharge

Implementation Overview

1) Explicit delineation of roles and responsibilities1) Explicit delineation of roles and responsibilities

2) Discharge process initiation upon admission2) Discharge process initiation upon admission

3) Patient education throughout hospitalization3) Patient education throughout hospitalization

4) Timely accurate information flow: 4) Timely accurate information flow: From PCP From PCP ►► Among Hospital team Among Hospital team ► ► Back to Back to PCPPCP

5) Complete patient discharge summary prior to discharge5) Complete patient discharge summary prior to discharge 6) Comprehensive written discharge plan provided to patient 6) Comprehensive written discharge plan provided to patient

prior to dischargeprior to discharge

7) Discharge information in patient’s language and literacy 7) Discharge information in patient’s language and literacy levellevel

8) Reinforcement of plan with patient after discharge8) Reinforcement of plan with patient after discharge

9) Availability of case management staff outside of limited 9) Availability of case management staff outside of limited daytime hoursdaytime hours

10) Continuous quality improvement of discharge processes10) Continuous quality improvement of discharge processes

Principles of the Newly Principles of the Newly Re-Engineered Hospital DischargeRe-Engineered Hospital Discharge

RED ChecklistEleven mutually reinforcing components:

1. Medication reconciliation 2. Reconcile discharge 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 understanding10. Discharge summary sent to PCP11. Telephone reinforcement

Adopted by

National Quality Forum

as one of 30 US

"Safe Practices" (SP-15)

RED Component #1Educate patient about their diagnosis throughout the

hospital stay

o The RED intervention starts within 24 hours of the patient’s admission to the hospital and continues daily until discharge

SP-15: “preparation for discharge occurring with documentation, throughout the hospitalization”

o Schedule PCP appointment within 2 weeks after discharge

o Review the provider’s location, transportation and plan to get to appointment

o Consult with patient regarding best day and time for appointments

o Discuss reason for and importance of all follow-up appointments and testing

SP-15: “explicit delineation of roles and responsibilities in the discharge process”

RED Component #2Make appointments for clinician

follow-up and post-discharge testing

RED Component #3 RED Component #3

Discuss tests/studies completed Discuss tests/studies completed and who will follow-up on resultsand who will follow-up on results

o Explain tests and studies done while in the Explain tests and studies done while in the hospital and tell the patient which clinician is hospital and tell the patient which clinician is responsible for reviewing the resultsresponsible for reviewing the results

o Encourage the patient to discuss tests Encourage the patient to discuss tests his/her PCP; let the patient know that this his/her PCP; let the patient know that this information will be listed on the AHCPinformation will be listed on the AHCP

SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge”

Red Component #4

Organize Post-discharge Services

o Collaborate with case manager and social worker about patient needs and post-discharge services

o Provide patient with contact information for these services (phone number, name of company, etc.)

RED Component #5Confirm the Medication

Plan

o Reconcile the patient’s home medication list upon admission to the hospital

o Review each medication; make sure that the patient knows why they take it

o Discuss new medications each day with medical team and with patient

SP-15 “completion of discharge plan and discharge summaries before discharge”

RED Component #6Reconcile discharge plan with

National Guidelines

o Communicate with medical team each day about the discharge plan

o Recommend actions that should be taken for each patient under a given diagnosis

RED Component #7Review appropriate steps for what to do if a problem arises

SP-15 “The time from discharge to the first appointment with the accepting physician represents a period of high risk. All patients discharged from hospitals should be told what to do if a question or problem arises, including whom to contact and how to contact them. Guidance should also be provided about resources for patients’ questions once they are discharged.”

o What constitutes an emergency

o What to do if a non-emergent problem arises

o Where to find contact information for the discharge advocate and PCP on the After Hospital Care Plan

RED Component #8Expedite transmission of the

discharge summary to the PCP

o Fax the discharge summary and AHCP to PCP within 24 hours after discharge

SP-15 “reliable information from the primary care physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods”

“A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.”

RED Component #9 Assess degree of understanding by asking

patient to explain the details of the plan

o Deliver information to reach those with low health literacy level

o Include caregivers when appropriate

o Utilize professional interpreters as needed

SP-15 "Before discharge, present a clear explanation that the patient understands that addresses post-discharge medications, how to take them and how and where prescription can be filled.  This information must also be communicated to the accepting physician.”

RED Component #10 Give the patient a written discharge

plan at time of discharge

o The AHCP should include:The AHCP should include:

1) Principal discharge diagnosis1) Principal discharge diagnosis

2) Discharge medication instructions2) Discharge medication instructions

3) Follow-up appointments with contact3) Follow-up appointments with contact

informationinformation

4) Pending test results 4) Pending test results

5) Tests that require follow up5) Tests that require follow up

SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge”

After Hospital Care Plan

RED Component # 11Provide telephone reinforcement

of the discharge plan after discharge

o Call patient within 72 hours after discharge

o Assess patient status

o Review medication plan

o Review follow-up appointments

o Take appropriate actions to resolve problems

SP-15 “Prospectively identify and provide a mechanism to contact patients with incomplete or complex discharge plans after discharge to assess the success of the discharge plan, address questions or issues that have arisen surrounding it, and reinforce its key components, in order to avoid post discharge adverse events and unnecessary re-hospitalizations" 

11 RED Components Enable 11 RED Components Enable Discharge Advocates to:Discharge Advocates to:

Prepare patients for hospital discharge

Help patients safely transition from hospital to home

Promote patient self-health management

Support patients after discharge through follow-up phone call

Challenges to Implementation:Medical Team Related

Busy medical team; discharge receives low priority in the work schedule of inpatient clinicians

Discharge is relegated to least experienced team member

Last minute test / consultations resulting in delay of final Last minute test / consultations resulting in delay of final discharge plan and medication list discharge plan and medication list

Inaccurate medication reconciliationInaccurate medication reconciliation

Discharge medication reconciliation started on the day of discharge

Challenges to Implementation:Hospital Related

Lack of resources and financial incentives to sustain discharge programs

Standardized discharge papers; not personalized or in language of patient

Resistance to change by clinicians

Financial pressure to fill beds as soon as they are empty 

Challenges to Implementation:Patient Related

Patient with no PCP

Limited or no insurance coverage

Inability to pay for medication co-pays

Long wait times calling health centers

Late discharge; less effective teaching to patients who are anxious to leave

Using Health IT to Overcome Challenge of RN Time

Potential in future to link to patient EMR so that information can flow into workstation

Assist in transferring clinical information between health care settings

Enhance patient education before discharge

Develop therapeutic alliance with patients

Help determine patient competency

Automated Discharge Workflow

SP-15 “the development of IT systems to collect discharge information and create discharge plans from existing hospital databases could enable components of the plan to be easily collected”

Conclusions

RED is NQF Safe Practice RED:

– Can be delivered following the 11 components and using the ACHP tool

– Can decrease hospital use 30% overall reduction Savings of $412 per patient

Success through elimination of barriers -- Coordination and change are challenging -- Providers must collaborate and work together Health IT could help

– Improve delivery– Further improve cost savings and build the

business case

Value Proposition

Hospitals– Improved HCAHPS scores

Potential reduction in malpractice claims– Prepared for changes to CMS reimbursement

penalties for high readmission rates– Improved relationship with private insurers

looking to contain costs– Improved nurse/provider time utilization– Demonstrated “Meaningful Use” under the

HITECH Act, eligibility for Medicare bonuses– Improved relationship with PCPs

Value Proposition cont’d

Insurers– Direct cost savings from reduced hospital

utilization ($412 per patient discharged)– Patient satisfaction– Improved long-term patient outcomes

Value Proposition cont’d

Providers– Improved nurse/provider time utilization– Demonstrated “Meaningful Use” under the

HITECH Act– Additional revenue from Current Procedural

Terminology (CPT) codes– Improved patient satisfaction

Value Proposition cont’d

Patients/Caregivers– Improved outcomes– Co-pays and premiums applied to more

effective services– Enhanced autonomy and ability to direct

care– Enhanced portability of personal health

records

Value Proposition cont’d

Primary Care Physicians/Other Specialists– Improved utilization and show rates by

patients– Improved transmission of information to

better care for patient Increased patient satisfaction

Ready for Project RED?

Next Steps– Secure leadership commitment

– Identify targeted populations to begin

– Determine approach for developing After Hospital Care Plan

– Identify staff: Project Leader, Project Team, Discharge Advocate(s)

Identify Targeted Patient Population

Start small! Approaches to consider

– Specific patient care unit

– Diagnostic group

– Physician’s patient group

– Combination of above

Also– English-speaking patients

– Discharged home

– Access to telephone

Generating the AHCP

“Manual” – use of template for discharge advocate (DA) to enter all required data

Provide template to your IT department and request that they integrate with existing systems

Purchase software and integrate it with your existing systems

To participate in JCR’s AHRQ-funded project focused on

Project RED

Contact Deborah Nadzam

dnadzam@jcrinc.com

630-261-5048