Project RED: The ReEngineered Discharge (Text Version)

On September 19, 2011, Brian Jack made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (11.1 MB). Plugin Software Help.

Slide 1

Project RED: The ReEngineered Discharge

Care Transitions: Navigating the Health Care System
AHRQ 2011 Annual Scientific Meeting
Bethesda, Maryland
September 19, 2011

Brian Jack MD
Professor and Vice Chair
Department of Family Medicine /
Boston University School of Medicine

Slide 2

Agenda for Today

1. Opportunities for improved transitions.
2. Policy implications.
3. RED checklist.
4. Evidence for RED.
5. Dissemination.
6. New AHRQ Toolkit.
7. Challenges to Implementation.

Slide 3

"Perfect Storm" of Patient Safety

• 39.5 million hospital discharges per year.
• Costs totaling $329.2 billion!
• Hospital discharge is not-standardized:
  • Loose Ends.
  • Communication.
  • Poor Information.
  • Poor Preparation.
  • Great Variability.
  • Fragmentation.
• 19% of patients have a post-discharge adverse events (AE).
• 20% of Medicare patients readmitted within 30 days.

Slide 4

A Real Discharge Instruction Sheet

Image: A filled out discharge instruction form is shown.

Slide 5

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:
    • www.hospitalcompare.hhs.gov.
    • Myocardial infarction (MI), congestive heart failure (CHF), pneumonia (PNA) → "Starter Set".
  • Payments changes for discharges beginning October 1, 2012.

Slide 6

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.
• 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".

Slide 7

Principles of the RED: Creating the Toolkit

Image: A flowchart showing the process of hospital discharge and patient readmission.

Slide 8

RED Checklist

Eleven mutually reinforcing components:

1. Medication reconciliation.
2. Reconcile dc 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 understanding.
10. Dc summary to PCP.
11. Telephone Reinforcement.

Adopted by National Quality Forum as one of 30 "Safe Practice" (SP-11).

Slide 9

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.

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).

Slide 10

Personalized Cover Page

Image: A sample cover page for an after hospital care plan.

Slide 11

Updated List of All Medicines

Image: A sample medication list with dosages and schedule.

Slide 12

Medication Page (2 of 3)

Image: Page 2 of a sample medication list with dosages and schedule.

Slide 13

Appointments Page

Image: A sample appointments page.

Slide 14

Appointment Calendar

Image: A sample appointment calendar.

Slide 15

Primary Diagnosis Page

Image: A brochure on congestive heart failure.

Slide 16

Primary Outcome: Hospital Utilization Within 30d After Dc

* Hospital utilization refers to ED + Readmissions.

Slide 17

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.

Slide 18

Outcome Cost Analysis

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

Slide 19

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.

Slide 20

Dissemination

• 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.

Slide 21

AHRQ Contract to Study Dissemination

Toolkit:

• 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.

Slide 22

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.

Slide 23

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?

Slide 24

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.

Slide 25

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.

Slide 26

Changing the Culture of Hospitals is Hard

"Culture Eats Strategy for Lunch"

Slide 27

Thank you!

brian.jack@bmc.org
http://www.bu.edu/fammed/projectred/ 

Image of staff involved in Project RED.

Slide 28

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.

Slide 29

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.

Slide 30

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.

Slide 31

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:
    • Lovenox.
    • Insulin.
    • Prednisone taper.

Image: To the right of the text is a drawing of two nurses named "Louise" and "Elizabeth".

Slide 32

Patient Interacting with Louise

Image: A patient interacting with the virtual nurse "Louise" is shown.

Slide 33

Who Would You Rather Receive Discharge Instructions From?

36% prefer agent.
48% neutral.
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.

Slide 34

Image: A group of people including AHRQ Director Dr. Carolyn Clancy and HHS Secretary Kathleen Sebelius.

Slide 35

Patient Activation Page

Image: A sample questions form for patients.

Slide 36

The Importance of Organizational Context

• Support of senior leader.
• Implementation team that engages frontline staff.
• Redesign work processes.
• Monitored progress.