Project REDRe-Engineered Discharge
Re-Engineering Discharge
The goal of this performance improvement (PI) project is to improve our discharge program
Project RED: – Is patient centered– Prepares patients to care for themselves at
home– Decreases readmissions and visits to the
emergency department
Presentation Outline
Impetus for project Strategic priorities PI structure Project RED components Role clarification Process
“Perfect Storm" of Patient Safety
39.5 million hospital discharges per year $329.2 billion in total annual costs Hospital discharge is not standardized and is marked with
poor quality- Loose ends- Poor communication - Poor quality information - Poor preparation - Fragmentation - Great variability
19 percent of patients have a post-discharge adverse event 20 percent of Medicare patients are readmitted within 30 days;
only half had a visit in the 30 days after discharge
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
Common Reasons for Avoidable Readmission -- Not Diagnosis-
Specific
Poor discharge instructions Patient doesn’t understand how to use
medications Patient doesn’t learn warning signs for when
to report to their physician Poor information transfer
From hospital to primary care physician (PCP)
From hospital to nursing home staff Lack of clarity on end-of-life care preferences
Common Reasons for Avoidable Readmission
Lack of timely post-discharge physician visit Physician unaware of hospitalization Patient has no PCP Patient lacks transportation
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 followup for heart failure patients
Readmissions higher for heart failure patients with behavioral problems
Diagnosis-Specific Reasons for Avoidable Readmissions
Post surgery Surgeons not arranging for post-surgical
primary care Post-CABG patients, expecting to be pain
free, seek readmission for angina Inadequate patient teaching on self care after
surgery (e.g., incision care) Dialysis patients very vulnerable to drug therapy
changes
Strategic Priorities
Improve patient outcomes and satisfaction Improve cost and revenue management Improve patient satisfaction scores Prepare for changes to CMS reimbursement
penalties for high readmission rates Improve nurse and provider time utilization Enhance portability of personal health information
across care continuum Improve relationship with PCPs
Specific Project Objectives Enter your specific objectives here
– Improve patient satisfaction with discharge preparation by ## percent
– Improve staff satisfaction with discharge process by ## percent
– Reduce readmissions by ## percent– Reduce post-discharge visits to the ED
Project Steering Committee
Vision Mandate improvement Identify champions Receive and review updates
Project Steering Committee
List team members Designate project team leader,
executive sponsor, and physician champion
Targeted Patient Population
To pilot Project RED, we have identified the following target patient population:– Provide diagnosis, unit, etc.
Baseline readmission rate = Average length of stay = Add stats from patient phone survey, if
available
Identifying Targeted Patientson Admission
How will you first identify that a newly admitted patient is in the targeted population for this project?
How will the Discharge Advocate (DA) be notified that a potential patient for Project RED has been admitted?
What secondary screening criteria for patient inclusion will the DA use to confirm the use of the Project RED intervention with the patient?
How will the DA track activities with new patients?
Patient and Family Centered Safe Care
Pre Patient Admission
H&P; Assessments; Rx Plan
PATIENT EDUCATION/Prepare for Home
Discharge Order
Written
Discharge Process Discharge Event
FINAL DISCHARGE INSTRUCTIONS
Post-D/C FOLLOW-UPMEDICATION MANAGEMENT
Discharge Folder
Passport for Home
White Board, Rounding & Bedside Report
Community providers: • Nursing Home• Home Health &
Hospice• Home Care• Physicians
• Accountable Care Organizations
Project RED Principles
Re-Engineered DischargePrinciples
1. Explicit delineation of roles and responsibilities2. Discharge process initiation upon admission3. Patient education throughout hospitalization4. Timely accurate information flow:
From PCP ► Among hospital team ► Back to PCP
5. Complete patient discharge summary prior to discharge
6. Comprehensive written discharge plan provided to patient prior to discharge
7. Discharge information in patient’s language and literacy level
8. Reinforcement of plan with patient after discharge
9. Availability of case management staff outside of limited daytime hours
10. Continuous quality improvement of discharge processes
Re-Engineered DischargePrinciples
RED Checklist12 mutually reinforcing components:1. Ascertain need for and obtain language assistance2. Medication Reconciliation 3. Reconcile discharge plan with national guidelines4. Follow-up appointments5. Outstanding/pending lab & diagnostic tests follow-up6. Post-discharge services7. Written discharge plan8. What to do if problem arises9. Patient education10. Assess patient understanding11. Discharge summary sent to PCP12. Telephone reinforcement
Adopted by National Quality Forumas one of 30 U.S. "Safe Practices"
Keys to the Project RED Intervention
DA– Related multidisciplinary activities
Care plan for patient use after discharge Post-discharge followup with patient
Discharge Advocate
Coordinates all discharge activities within patient population
Facilitates team activities and discharge planning rounds with primary doctor
Collects discharge-focused data Ensures Patient Care Plan is completed and
patient understands the information and can comply with the instructions in the plan
Discharge Advocate Is notified when patients in the target
population are admitted or diagnosed Initiates action steps associated with Project
RED Initiates the Patient Care Plan Educates patient and family about condition,
medications, treatments, post-discharge plans, and followup ordered by the physician
Reviews Patient Care Plan with patient and family
Collects measurement data on project and patient population
Discharge Advocate
Project RED’s 12 components let the DA:– 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
Staff Member Roles
Patient’s physician and medical team Nursing staff Case management Pharmacists
Patient’s Physician Initiates patient plan of care based on critical
pathway Leads or participates in discharge planning
rounds Communicates potential discharge date Supports the PI process
Nursing Staff
Provide nursing care Educate patient and family Communicate with each other Communicate with other members of the health
care team, including DA Participate in multidisciplinary rounds, including
those focused on discharge planning
Pharmacist
Verifies physician orders Reconciles admission medications with
medications from home Collaborates with care team specific to
discharge needs Reconciles medications upon discharge Assists with patient medication questions
Case Managers
Arrange post-discharge services Educate the patient Perform social work duties Perform utilization review
Other Key Staff
Therapists Disease management
Discharge Planning Rounds Consider daily discharge rounds
– Medical staff, nursing staff, pharmacy, case management, and DA
When is discharge order written?– Was it expected?– Weekend discharge?– Is there a timing expectation (e.g., time
from when the order is written to when the patient is out the door)?
Patient Care Plan Date of discharge Name and contact information for physician and DA Medications Pending tests and results Follow-up appointments Calendar Other orders (diet, activity, etc.) Information about disease or condition When to call physician or seek emergency care Form for writing down questions Map for locating appointments (optional) Other information about your center (optional)
Patient Care Plan
Accessing the template Accessing information Saving Printing Storing
– Will completed Patient Care Plan become part of the patient record?
Complete the Patient Care Plan
Medication reconciliation Pending tests and results Post-discharge services Primary care provider Follow-up appointments Information about condition
Medication Reconciliation
Hospital procedure for completing medication reconciliation at discharge
DA participates and conducts final check on medications
DA populates Patient Care Plan (e.g., medication purpose, time of day taken)
DA uses final list to teach the patient
Pending Tests and Results
Obtains information about tests and studies completed and still-pending results
Adds pending test results to the designated spot on the Patient Care Plan, including which clinician is responsible for getting final results
Points out where the information is on the Patient Care Plan
Encourages patient to discuss tests with PCP
Post-Discharge Services
Confirms with case manager that all services have been arranged
Adds names and contact information of service providers to Patient Care Plan
Primary Care Provider
Confirms name of PCP with patient Adds name and contact number of
PCP to Patient Care Plan
Follow-up Appointments
Discusses best days of week and times of day with patient
Discusses transportation needs Calls clinicians’ offices to make
appointments that meet patient’s time options– For off-hour or weekend discharges,
leaves message with clinician’s office to call patient
Adds appointments to Patient Care Plan
Information About Condition
Obtains information about the patient’s condition to add to Patient Care Plan
Includes– Signs and symptoms that warrant followup
with clinician– Signs and symptoms that warrant
emergency care– Contact information for the DA and PCP
(phone numbers, paging instructions)
Post-Discharge Activities
Transmits discharge summary and Patient Care Plan to PCP– By fax: Ensures it is received and legible– By e-mail: Ensures it is received
Makes follow-up phone call to patient– Uses script that includes medications and
follow-up appointments– Determines need for second call by clinician
Communication and Coordination
Hospital discharge process is often characterized by poor communication and a lack of coordination between the hospital and the PCP
Patients often do not know what medications their physicians prescribed, when follow-up appointments should take place, and, in some cases, why they were hospitalized
Primary Care Physician Referral Base
Leaders identify the PCP referral base
Hospital assesses PCP satisfaction before project launch
Physician champion communicates with PCPs about project
PCPs advise how to handle off-shift and weekend patient needs
Post-Discharge Phone Call
Decide who calls the patient after discharge Decide when the follow-up call will be made Develop the caller’s script Develop the process for off-shift and weekend
discharges
Process Measurement
Measure the project to determine impact– Outcome measures– Process measures– Resource investment
Results will determine if Project RED will be used in other areas of the hospital
Process Metrics
Average time to notify DA about new admission Average time from admission to first patient visit by
DA (initiation of care plan) – only for patients who meet all criteria
Percent of patients’ PCPs notified within 24 hours discharge
Percent of follow-up phone calls made within 48 hours
Percent of follow-up calls requiring second call by pharmacist (if non-pharmacist makes first call)
Percent of patients completing post-discharge survey (30 days after discharge)
Process Metrics
Completion of care plan details– Percent of care plans with medication list
included– Percent of care plans with care needs included
(e.g., exercise, diet, main problem, when to call doctor)
– Percent of care plans with follow-up appointments listed
– Percent of care plans with pre-arranged discharge resources identified (e.g., home health, durable medical equipment)
– Percent of care plans with pending tests listed
Outcome Metrics for Target Population
Average length of stay (LOS) 30-day unplanned readmission rate Cost of second LOS (readmission) Pre/post data: Patient experience related to
discharge preparation Pre/post data: Frontline staff survey related
to discharge preparation Project costs Discharge process costs (current and
redesigned)
Project Launch
Expected start date Targeted population or unit DA’s name and contact information Project leader’s name and contact
information Physician champion’s name and contact
information
Questions