Project RED: Reengineering the Discharge Process

Agency for Healthcare Research and QualityAdvancing Excellence in Health Care • www.ahrq.gov

Project RED:Reengineering the Discharge Process

The Patient Centered Discharge Process HCAHPS PSLN

May 18, 2012

Michael Paasche-Orlow MD, MA, MPH Associate Professor of Medicine

Boston University School of Medicine

Advancing Excellence in Health Care Acknowledgements

This program is supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) through a contract with the Health Research and Educational Trust (HRET).

HRET is a charitable and educational organization affiliated with the American Hospital Association, whose mission is to transform health care through research and education.

AHRQ is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.

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Advancing Excellence in Health Care

Top four HCAHPS Priorities of over 430 hospitals participating in 18 HCAHPS PSLNs:

1. RN Communication2. Responsiveness3. Medication Communication*4. Discharge Information*

* Addressed by the patient-centered discharge process under Project RED

Why a Project RED Webinar for HCAHPS PSLN Participants?

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Staff Always Explained About MedicinesUnited States, 2008-2010


Patients Given Information About Recovery At HomeUnited States, 2008-2010


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84.5% - 88.5% (78)

82.6% - 84.4% (80)

80.7% - 82.5% (75)

73.8% - 80.6% (73)

Not Populated

Percent of Patients (HRRs)

HRR = hospital referral region.Data: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) as reported by CMS Hospital Compare, 2010 (analysis by IPRO).

Source: Commonwealth Fund Scorecard on Local Health System Performance, 2012.

Percent of hospitalized patients given information about what to doduring their recovery at home

PREVENTION & TREATMENT


Scale: Strongly Disagree, Disagree, Agree, Strongly Agree

During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.

When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.

When I left the hospital, I clearly understood the purpose for taking each of my medications.

New HCAHPS Care Transitions Questions

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New care transitions questions available in HCAHPS on a voluntary basis beginning with July 1, 2012 discharges

New care transitions questions proposed to become mandatory in HCAHPS beginning with January 1, 2013 discharges

Timing of HCAHPS Integration

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June 25, 2012, 11:30-12:30pm EDT—Using the Medication Reconciliation Process for Medication Communication

Two expert authors of the new AHRQ Medication Reconciliation toolkit, Kristine Gleason, RPh, and Helga Brake, PharmD, of Northwestern Memorial Hospital, will teach how to use the new AHRQ toolkit for medication communication.

Registration URL:

http://event.on24.com/r.htm?e=462520&s=1&k=111F339A38B513C651360711DCA5E847

Dial-In Information: 1-866-710-0179 / Passcode: 846 488

You’re Invited: Free Web Conferences for all PSLN Participants

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A national PSLN meeting will take place June 20 (in the same hotel as the national TeamSTEPPS conference on June 21-22): https://register.rcsreg.com/r2/tsnational2012/ga/top.html Date: June 20, 2012 Registration is free Location: Sheraton Nashville Downtown – Nashville, TN Contact for more information: Jennifer Shaw at

[email protected]

Meeting Objectives: Identify and share PSLN effective peer-to-peer learnings To connect patient experience of care to improvement work To connect teamwork and culture to improvement work

You’re Invited to the National AHRQ/HRET Patient Safety Learning Networks Meeting

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Learning Network Faculty

Michael Paasche-Orlow, M.D., M.A., M.P.H., Associate Professor, Boston University, Co-Investigator for Project RED

Dr. Paasche-Orlow is a practicing general internist in the Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine.

Health Literacy is the central focus of Dr. Paasche-Orlow’s research career. Besides research relating to rehospitalization, Dr. Paasche-Orlow has examined the role of health literacy in a range of circumstances including medication adherence, mental health, informed consent, disparities, asthma, behavioral interventions, and end-of-life decision-making.

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Declaration of COI

Dr. Paasche-Orlow is a consultant for Engineered Care, Inc., a firm that markets patient education software to hospitals.

http://www.engineeredcare.com

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http://www.engineeredcare.com/

http://www.engineeredcare.com/index.html


Tremendous Attention on Rehospitalization

Efficiency– Decreasing readmissions allows for the

alignment of improving quality and decreasing cost.

Plentiful– 2006: 39.5 million hospital discharges with costs

totaling $329.2 billion!

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Patient Protection and Affordable Care Act

Transitions of Care– Accountable Care Organizations 1/1/2012

– Community Care Transitions Program ACA Sec. 3026

– Expanding Authority to Bundle Payments– Value-Based Purchasing

http://www.hospitalcompare.hhs.gov/ MI, CHF, PNA “Starter Set” Effective for payments for discharges occurring on or

after October 1, 2012.

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Characteristics of Hospital Discharge

Not standardized and frequently poor quality Loose Ends Fragmentation Poor Quality Information Poor Preparation

• 20% of Medicare patients readmitted within 30 days

• Only half had a visit in the 30 days after discharge Source: N Engl J Med 2009 2;360(14):1418-28.

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Patients Are Not Prepared at Discharge

At Discharge:

• 37% able to state purpose of all medications

• 14% knew the common side effects

• 42% able to state their diagnosis

Source: 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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Time Spent on Discharge

Audiotaped 97 discharge encounters Nurse, Pharmacist, Physician, Nurse Case

Manager Averaged 8 minutes (range, 2 to 28.5 min)

No teach back 84% of the time

Patient is a passive participant (95/97)

Not comprehensive

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Communication Barriers

Patients with communication problems:– 3 times more likely to have adverse event– 46% had multiple adverse events

Source: Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Gillian Bartlett, PhD, Régis Blais, PhD, Robyn Tamblyn, PhD, Richard J. Clermont, MD and Brenda MacGibbon, PhD CMAJ. June 2008;178(12)

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Errors Lead to Adverse Events

19% of patients had a post-discharge AE 1/3 preventable and 1/3 ameliorable

23% of patients had a post-discharge AE• 28% preventable and 22% ameliorable19


Principles of the RED:Creating the Toolkit

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Process Mapping-1Ready for Discharge?

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RED ChecklistEleven mutually reinforcing components:

Patient education Follow-up appointments Outstanding tests Post-discharge services Medication reconciliation Reconcile dc plan with National Guidelines What to do if problem arises D/C summary to PCP Assess patient understanding Written discharge plan> Telephone Reinforcement

Adopted by

National Quality Forum

as one of 30

"Safe Practices" (SP-15)

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RED Component #1

Educate patient about their diagnosis throughout their stay RED intervention starts within 24 hours of the

patient’s admission

Continues daily until discharge

How is this done in your organization? Who is involved? How do you know if you are succeeding?

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Advancing Excellence in Health Care RED Component #2

Make appointments for clinician follow-up and post-discharge testing

Schedule PCP appt within 2 weeks after discharge

Review the provider, location, transportation and plan to get to appointment

Consult with patient regarding best day and time for appointments

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

How is this done in your organization? Who is involved? What % of patients who leave your facility get an appointment in 2 weeks?24

Advancing Excellence in Health Care RED Component #4

Organize post-discharge services

Communicate with case manager and social worker about post-discharge services that they schedule

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

Are there any ways you feel this needs to be improved?

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RED Component #5Confirm the Medication Plan

Reconcile the patient’s home medication list as close to admission as possible

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

Discuss new medications each day with medical team and with patient

What is your current plan to improve?

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RED Component #7

Review appropriate steps for what to do if a problem arises

What constitutes an emergency?What to do if a non-emergent problem arises?Where is contact information found for the discharge advocate and PCP on the After Hospital Care Plan?

What are you doing now and what is your current plan to improve?

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RED Component #9

Assess degree of patient understanding, ask patient to explain discharge plan

Deliver information to reach those with low health literacy

Include caregivers when appropriate

Utilize professional interpreters as needed

How are you doing now and what is your current plan to improve?

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RED Component #10

Give the patient a written discharge plan at time of discharge

After Hospital Care Plan includes:1) Principal discharge diagnosis2) Discharge medication instructions3) Follow-up appointments with contact information4) Pending test results 5) Tests that require follow-up

How are you doing now and what is your current plan to improve?

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RED Component # 11

Provide telephone reinforcement of the discharge plan after discharge

Call patient within 72 hours after discharge Assess patient status Review medication plan Review follow-up appointments Take appropriate actions to resolve problems What are you doing now and what is your current plan to improve?

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Operationalizing RED

After Hospital Care Plan Discharge Advocate Follow-up phone call

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After Hospital Care Plan

Patient-centered discharge instruction booklet Designed to reach pts w/ low health literacy Individualized for each patient and organization

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COVER PAGE of AFTER HOSPITAL CARE PLAN

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MEDICATION PAGE (2 of 3)

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PATIENT ACTIVATION PAGE

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Components of RED Intervention

In acute care facility – Nurse Discharge Advocate (DA) – Interacts with care team: medication reconciliation,

appointments, and national guidelines– Prepares and teaches After Hospital Care Plan

(AHCP)

Post Discharge – Clinical Pharmacist– Calls for follow-up @ 72 hours post-dc– Reinforces dc plan and review medications

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Testing the RED Process:Randomized Controlled Trial

Advancing Excellence in Health Care Randomized Controlled Trial

EnrollmentN=749

Randomization

RED InterventionN=374

Usual CareN=375

30-day Outcome Data• Telephone Call• EMR Review

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) 48% Medicaid + 22% Free Care

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Advancing Excellence in Health Care 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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Primary Outcome: Hospital Utilization within 30d after dc

Usual Care (n=368)

Intervention (n=370)

P-value

Hospital Utilizations *Total # of visits Rate (visits/patient/month)

1660.451

1160.314 0.009

ED VisitsTotal # of visitsRate (visits/patient/month)

900.245

610.165 0.014

ReadmissionsTotal # of visits Rate (visits/patient/month)

760.207

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0.149 0.090

* Hospital utilization refers to ED + Readmissions

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Cumulative Hazard Rate of Patients Experiencing Hospital Utilization

30 days After Index Discharge

0 5 10 15 20 25 30

0.0

0.1

0.2

0.3

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azar

d R

ate

Time after Index Discharge (days)

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Usual care Interventionp = 0.004


Outcome Cost Analysis

Cost (dollars)Usual Care

(n=368)Intervention (n=370) Difference

Hospital visits 412,544 268,942 +143,602

ED visits 21,389 11,285 +10,104

PCP visits 8,906 12,617 -3,711

Total cost/group 442,839 292,844 +149,995

Total cost/subject 1,203 791 +412

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

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RED Workstation

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Advancing Excellence in Health Care Patient Centered Care Transitions

Significant Cultural Change Shifting to service mentality

Culturally and Linguistically Appropriate Across the care continuum

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Advancing Excellence in Health Care For more information

Project RED Websitehttp://www.bu.edu/fammed/projectred/

Engineered Care [email protected]

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http://www.bu.edu/fammed/projectred/

mailto:[email protected]


Questions?

Question for you:Do you have the power you need on your project team to transform your organization?


June 28, 2012, 12:30-2pm EDT—Special CMS Web conference on HCAHPS and Value-based Purchasing (VBP) Elizabeth Goldstein and William Lehman of CMS will

talk about HCAHPS, the new care transitions questions, and the changing relationship of HCAHPS to VBP.

Registration URL: http://event.on24.com/r.htm?

e=461086&s=1&k=05322FB79924399145DFD0A9C0097299

Dial-In Information: 1-866-710-0179 / Passcode: 954 683

You’re Invited: Multistate Web Conference on HCAHPS and VBP for all PSLNs

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Project RED: Reengineering the Discharge Process

Documents

Transcript of Project RED: Reengineering the Discharge Process