Testing the R e- E ngineered D ischarge
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Transcript of Testing the R e- E ngineered D ischarge
Testing the Re-Engineered
Discharge
Principal Investigator: Brian Jack MD Associate Professor and Vice Chair
Department of Family MedicineBoston Medical Center /
Boston University School of Medicine
Hands-On Health LiteracySeptember 9, 2008
Loose Ends - workups NOT completed
Communication - DC summary not available
Poor Quality Info - DC summary lack results
Poor Preparation - few pts know meds/dx
Fragmentation - who is in charge?
“Perfect Storm”of Patient Safety“
Principles of the RED:Creating the Toolkit
Adopted by National Quality Forumas one of 30 "Safe Practices" (SP-11)
Eleven mutually reinforcing components:
Medication Reconciliation Reconcile Plan with National Guidelines Follow-up Appointments Outstanding Tests and Studies Post-discharge Services Written discharge plan What to do if a problem arises Patient Education Assess patient understanding Dc summary to PCP> Telephone Reinforcement
RED Checklist
In Hospital - Discharge Advocate (DA) Nurse Interact with care team – med rec and guidelines Prepare the After Hospital Discharge Plan (AHCP) Teach the AHCP
After Discharge – Clinical Pharmacist Follow-up call @ 2-3 days
The DA and Pharm manual Scripts for each task
Intervention to Administer RED
EnrollmentN=750
Randomization
RED Intervention
Usual Care
30 day Outcome DataTelephone CallChart Review
Informed Consent
Testing the RED Schematic
ExtremelyVeryModeratelyA little bitNot at all
How useful was the booklet to you?
AHCP Evaluation:30 days post-discharge
19%
39%21%
17%
4%
What was the most helpful part of the booklet?
AHCP Evaluation:30 days post-discharge
Medical Provider Information
RED Medication Schedule
Appointment Page
Appointment Calendar
Diagnosis Information
Other
25%
20%
15%
13%
12%
15%
How helpful was the RED medication calendar?
AHCP Evaluation:30 days post-discharge
ExtremelyQuite a bitModeratelyA little bitNot at all
4%
26%
45%
9%
15%
Self-PerceivedReadiness for Discharge 30 days post-discharge
Control (n=376) Intervention (n=373)
P-value
Hospital UtilizationTotal # of visits Rate
16744/100 subjects
11631/100 subjects <0.00
1
ED Total # of visitsRate
9024/100 subjects
6116/100 subjects 0.01
RehospitalizationTotal # of visits Rate
7721/100 subjects
55
15/100 subjects 0.05
Primary Outcome
Cumulative Hazard of Patients Experiencing an Hospital Utilization in 30d After Index Discharge
0 5 10 15 20 25 30
Days after Discharge
0.5
0.6
0.8
1.0
Pro
bab
ilit
y o
f su
rviv
al
---- RED---- Usual Care Chi-square p=0.005
RED: • Successfully delivered using
– RED protocols– AHCP
• Improves ‘Readiness for Discharge’• Decreases hospital use
– 32% reduction– NNT = 7.9
• Helps high hospital utilizers– 40% reduction
• Is Cost-Effective– $329 / patient – 38 million discharges @ $753 billion x 32% eligible = 4 billion
Conclusions from the RCT
• Embodied Conversational Agent – Teaches the AHCP– Emulates face to face communication– Develops therapeutic alliance
• Empathy• Gaze, posture, gesture
– Competency Questions– Can drill down in med education– Maps of test sites and CHCs– Instructions – e.g., Lovenox, Glucometer
• Workstation database– Connects to hospital IT– Prints AHCP – “Feeds” Louise
• Concordancy Studies • Kiosk for patient access
Major Problem: RN TimeCan Health IT Help?
Louise
Social Chat
Cover
Medications
Appointments
Diagnosis
Closing
• Juan Fernandez• David Anthony, MD, MSc• Tim Bickmore PhD• Gail Burniske, PharmD• Kevin Casey, MPH• VK Chetty, PhD• Allyson Correia, RN• Larry Culpepper, MD, MPH• Shaula Forsythe, MPH, MS• Rob Friedman, MD• Jeffrey Greenwald, MD• Anna Johnson• Anand Kartha, MD• Christopher Manasseh, MD• Julie O’Donnell
• PI: Brian Jack, MD• Michael Paasche-Orlow MD, MPH• Caroline Hesko, MPH• Irina Kushnir• Fiana Gershengorina• Kim Visconti, RN• Jared Kutzin, RN, MPH• Alison Simas, RN• Mary Goodwin, RN• Lynn Schipelliti, RN• Lindsey Hollister• Maggie Jack• Kacie Fyrberg, RN• Vimal Jhaveri• Laura Pfeifer
Thank You AHRQ!