Re-Engineered Discharge (RED) Toolkit

National Quality Forum Safe Practice Discharge Measures

The principles of the RED program were incorporated into the National Quality Forum (NQF) Safe Practice as being essential for delivery of a safe and effective hospital discharge. The components of the NQF Safe Practice were harmonized with the recommendations of the Joint Commission, the Leapfrog Group, Centers for Medicare & Medicaid Services (CMS), the Institute for Healthcare Improvement, and others and mirror the components of the RED program.⁶

The NQF Safe Practice does not target the rehospitalization rate as a key indicator, but identifies a key set of intermediate process variables leading toward rehospitalization. These performance measures do not all address external reporting requirements, but are suggested to support internal health care organization quality improvement efforts. The measures endorsed by the NQF are listed below.

• Outcome measures include reduction in direct harm associated with adverse events and treatment misadventures, including death, disability (permanent or temporary), adverse drug events, or preventable harm requiring further treatment; missed diagnoses and delayed treatment; and inaccessible prior test information and medical records.
• Process measures include the percentage of discharge summaries received by accepting practitioners; the number of patients who have and attend a posthospital followup appointment; and the timeliness of receipt and discussion of posthospital followup tests with the accepting provider.
• Home management plan of care document given to patient/caregiver requires that documentation exists that the home management plan of care (HMPC), as a separate document, specific to the patient, was given to the patient/caregiver prior to or upon discharge.
• Structure measures include verification of the existence of a systematic hospital discharge performance improvement program and explicit organizational policies and procedures addressing communication of discharge information; verification of educational programs; and the existence of formal reporting structures for accountability across governance, administrative leadership, and frontline caregivers.
• Patient-centered measures include surveys of patient satisfaction about hospital discharge at the time of and after discharge. The NQF-endorsed HCAHPS® survey includes two relevant measures: "During your hospital stay, did hospital staff talk with you about whether you would have the help you needed when you left the hospital?" (Q19); and "During your hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?" (Q20). Additional self-report surveys, such as the 3-Item Care Transition Measure (CTM-3), may be considered as well.

American College of Cardiology H2H (Hospital to Home) Program

Another organization that has set a specific target for rehospitalization rate improvement is the initiative that is co-led by the American College of Cardiology and the Institute for Healthcare Improvement. Other strategic partners include specialty societies, nursing organizations, hospital associations, integrated health systems, payers and patients, and family caregivers. The focus of this program is on medication management postdischarge, early followup, and symptom management. The overall goal of the h3H initiative is to reduce all-cause readmission rates among patients discharged with heart failure or acute myocardial infarction by 20 percent. The Web site is available at www.h3hquality.org.

ABIM, ACP, SHM Care Transitions Performance Measurement Set

The American Board of Internal Medicine Foundation, American College of Physicians, and Society of Hospital Medicine have released the Physician Consortium for Performance Improvement®—Care Transitions Performance Measurement Set.⁷ This document lists key measures of success in improving outcomes, including:

• Reduction in adverse drug events.
• Reduction in patient harm related to medical errors of omission and commission.
• Reduction in unnecessary health care encounters (e.g., 30-day all-cause hospital readmissions).
• Reduction in redundant tests and procedures.
• Achievement of patient goals and preferences (e.g., functional status, comfort care).
• Improved patient understanding of and adherence to treatment plan.

CMS Safe Transitions Program Technical Expert Panel Recommendations

The CMS Community-Based Care Transitions Program^8,9 has implemented demonstration projects in 14 Quality Improvement Organizations (QIOs) in 14 States representing more than 1 million beneficiaries. As part of this effort, the Technical Expert Panel (TEP) on Benchmarking of Hospital Discharge was formed to study and make recommendations about transition measures. The final report assists hospitals to understand how CMS is approaching the issue of rehospitalization measures.

The measures  the TEP recommended include:

• Patient satisfaction.
• Standardized elements of discharge process.
• Scheduling of followup visit.
• Elements of transition.
• All-cause 30-day readmission rates.
• Intervening physician visits among those readmitted.

The TEP identified the following examples of optimal measures for hospital discharge transitions. The expected rates of improvement are shown in Table 1.

• 30-day readmission rate.
• 30-day all-cause risk standardized readmission rate following congestive heart failure (CHF), acute myocardial infarction (AMI), and pneumonia.
• Percentage of patients who rate hospital performance meeting HCAHPS performance standard for discharge information and information about medicines.
• Percentage of patients readmitted ≤30 days not seen by a physician between discharge and readmission.
• Percentage of care transitions in the targeted area for which interventions show improvement.

Table 1. Expected rates of improvement

It appears that 30-day all-cause rehospitalization rates will be a key measure. For the purpose of quality improvement, the raw rates of rehospitalization are probably sufficient. However, when hospitals are compared in the public domain or for purposes of reimbursement, then risk adjustments are necessary (go to How CMS Measures the "30-Day All Cause Rehospitalization Rate" on the Hospital Compare Web Site). If readmission rates are to be a key measure, then it is important that the definition be clear and the calculation of this rate be consistent. Although there is not yet a national consensus, the TEP suggested:

• Including those discharged from short-term acute care facilities in the denominator.
• Including readmission to an acute care hospital or having observation stay within 30 days of index hospital discharge, whether planned or unplanned, in the numerator.
• Excluding patients who died during index hospitalization.
• Excluding emergency department visits from the numerator or denominator.
• Treating admission to and from chronic care facilities like any other hospitalization.
• Including all payers, including all Medicare beneficiaries.
• Tracking the proportion of readmissions to same versus other hospitals.
• Using current risk-standardized measures (go to How CMS Measures the "30-Day All Cause Rehospitalization Rate" on the Hospital Compare Web Site).
• Refraining from using unadjusted measures to compare hospitals to each other.

The TEP also recommended that the calculation of physician followup include:

• Beneficiaries in community ZIP Code with a readmission to short-term acute care facility (including chronic care facilities) within 30 days of index hospital discharge in the denominator.
• The presence of any Part B evaluation and management (E&M) code between discharge and readmission in the numerator.