reducing readmissions through the re-engineered discharge – (project red) suzanne mitchell, md ms...
TRANSCRIPT
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Reducing Readmissions through The Re-Engineered Discharge –
(Project RED)
Suzanne Mitchell, MD MSAssistant Professor, Family Medicine
Department of Family Medicine / Boston University School of Medicine
March 25, 2014
Participants:1-866-639-0744, no code needed
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The Re-Engineered Discharge (Project RED)
Suzanne Mitchell, MD MSAssistant Professor, Family MedicineDepartment of Family Medicine / Boston University School of Medicine
March 25, 2014
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Agenda
I. The Transition ProblemII. How We Got Started III. The RED ProcessIV. Brief Mention of Health IT?V. Lessons Learned from Dissemination
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“Perfect Storm" of Patient Safety
• Loose Ends - pending and post-dc tests• Communication – with PCP, ESL, Health lit• Poor Information - dc summary quality and availability • Poor Preparation – knowledge of dx, meds, appts • Great Variability – day of the week• Fragmentation – who is in charge?
• Hospital Discharge is not safe!• 19% of patients have a post-discharge AE
• 39.5 million hospital discharges/year = Costs totaling $329.2b!• 20% readmitted within 30 days
• Hospital discharge is not-standardized:
“Perfect Storm" of Patient Safety
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A Real Discharge Instruction Sheet
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ResearchQuestionsWe asked:• Can improving the discharge process reduce adverse events and
unplanned hospital utilization?
Grant reviewer asked:• What is the “discharge process”?
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Question for you……• Do you know what your hospital’s discharge process is?
• Do you know the parts of the process where problems are occurring for patients or hospital personnel?• ie, occurring before or following discharge?
• How are you identifying the problem spots?
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Principles of the RED:Creating the Toolkit
Readmission Within6 Months
HospitalDischarge
Patient Readmitted
Within 3 Months
Probabilistic Risk
Assessment
Process Mapping
Failure Mode and Effects
Analysis
QualitativeAnalysis
Root CauseAnalysis
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THE RED INTERVENTIONTHE RED INTERVENTIONTwo key componentsTwo key components
• In HospitalIn Hospital –> Preparation & Education of written plan –> Preparation & Education of written plan
• AHCPAHCP
• After DischargeAfter Discharge – Reinforcement of the plan – Reinforcement of the plan
• Phone call within 72 hours after dischargePhone call within 72 hours after discharge
• Assess clinical statusAssess clinical status
• Review medications and appointmentsReview medications and appointments
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RED ChecklistTwelve mutually reinforcing components:
1. Medication reconciliation 2. Reconcile dc plan with National Guidelines3. Follow-up appointments4. Outstanding tests 5. Post-discharge services6. Written discharge plan7. What to do if problem arises8. Patient education9. Assess patient understanding10. Dc summary to PCP11. Telephone Reinforcement12. Provide Language Services
Adopted by
National Quality Forum
as one of 30
"Safe Practices" (SP-11)
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EnrollmentN=750
Randomization
RED InterventionN=375
Usual CareN=375
30-day Outcome Data•Telephone Call•EMR Review
RCT Methods-
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)
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Personalized cover page
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MEDICATION PAGE (2 of 3)
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APPOINTMENTS PAGE
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PRIMARY DIAGNOSIS PAGE
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Question for you……• Does your institution have a patient-centered discharge
document?
• If no, what are the barriers to providing such a document?
• If yes, • What are the design elements that facilitate communication?
• What design elements support patient self-management?
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FINDINGS from Project RED RCT
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How well did we deliver intervention
RED Component Intervention Group (No,%)(N=370) *
PCP appointment scheduled 346 (94%)
AHCP given to patient 306 (83%)
AHCP/DC Summary faxed to PCP
336 (91%)
PharmD telephone call completed
228 (62%)
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Primary Outcome: Hospital Utilization within 30d after Discharge
Usual Care (n=368)
Intervention (n=370)
P-value
ReadmissionsTotal # of visitsRate (visits/patient/month
76
0.2055
0.15
ED VisitsTotal # of visitsRate (visits/patient/month)
900.24
610.16
Hospital Utilizations *Total # of visits Rate (visits/patient/month)
1660.45
1160.31 0.009
* Hospital utilization refers to ED + Readmissions
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Secondary Outcomes
Usual Care(n=368)
Intervention (n=370)
P-ValueNo. (%) No. (%)
PCP follow-up rate 135 (44%) 190 (62%) <0.001
Identified dc diagnosis 217 (70%) 242 (79%) 0.017
Identified PCP name 275 (89%) 292 (95%) 0.007
* *
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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 We saved $412 in outcome costs for each patient given REDRED
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Medication Errors at 2 Day Call (n=197)
Incorrect Administration No. (%)
Wrong frequency/interval 39 (21%)
Wrong dose on prescription 33 (18%)
Failure to take medication No. (%)
Patient did not think s/he needs med 19 (15%)
Patient did not fill due to cost 21 (17%)
Patient did not pick up from pharmacy 14 (11%)
Patient did not get prescription on discharge 15 (12%)
Patient self-discontinued due to side effects 14 (11%)
Patient did not fill because of insurance 10 (8%)
Overall, 51% experienced error within 2 days!
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Question for you…..• Have you tried any strategies to communicate with patients
following discharge?
• Are you able to make PCP appointments at the time of discharge?
• What strategies are you using for medication reconciliation at the time of discharge?
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Implications
Should all patients get RED?
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Question for you…..
• Is your institution doing risk stratification at the time of admission?
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Who is at risk of Rehospitalization?• CHF, COPD,
Dementia• High risk Meds• Elderly• LOS• Co-morbidity• Men• Substance Abuse
• Health Literacy (REALM)
• Depression (PHQ-9)• Patient Activation
(PAM)• Frequent Fliers (>2 in
6 months)
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Can Health IT assist with providing a comprehensive
discharge?
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Virtual Patient Advocates
• Emulate face-to-face communication• Develop therapeutic alliance-empathy, gaze, posture, gesture• Teach AHCP• Tailored • Do “Teach Back”• Can drill down• Print Reports • High Risk Meds
LovenoxInsulin
Health IT to Save Time
Characters: Louise (L) and Elizabeth (R)
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Overall Usability
Overall SatisfactionEase of Use
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Who Would You Rather Receive Discharge Instructions From?
1=definitely prefer doc, 4=neutral, 7=definitely prefer agent
36% prefer Louise48% neutral16% 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.”
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Question for you…..• Is your institution using health IT to streamline the hospital
discharge process?
• What processes are you automating?
• What are the benefits/challenges of using health IT for discharge process?
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Barriers to RED
• Can appointments be made?• Will RED delay discharge time?
• Who serves as the Discharge Educator? • Who does the 2 day phone call?
• Who Produces the AHCP?
Can we Re-Engineer the Hospital Ward?
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Success storiesSuccess storiesBoston HealthNet planBoston HealthNet plan
Period -> calendar year 2011Period -> calendar year 2011
Patients given RED -> 500Patients given RED -> 500– Discharge educator = dedicated RNDischarge educator = dedicated RN– Post discharge phone call = plan’s care managerPost discharge phone call = plan’s care manager
Results -> 30 day all cause readmission rateResults -> 30 day all cause readmission rate
Cost savings -> well over 400kCost savings -> well over 400k
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RED for Boston HealthNet
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• Formal risk screeningFormal risk screening
• Process for patient educationProcess for patient education• Discharge educatorDischarge educator
• Developing and teaching ACHPDeveloping and teaching ACHP• PharmacistPharmacist
• Standardized communicationStandardized communication• Primary care providersPrimary care providers• Other providersOther providers
• Home careHome care• Nursing HomeNursing Home
RED Implementation – – Strategies During hospitalizationStrategies During hospitalization
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• Discharge Nurse EducatorDischarge Nurse Educator• Uses checklist Uses checklist • Assesses patient understanding of discharge planAssesses patient understanding of discharge plan
(Teach back process used)(Teach back process used)• Care TeamCare Team
• Discusses discharge plan Discusses discharge plan dailydaily at team huddle at team huddle
• PatientPatient• Receives individual written discharge planReceives individual written discharge plan
RED Implementation – Strategies Prior to Discharge
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• Discharge is not rushed or late in the dayDischarge is not rushed or late in the day
• AHCP and discharge summary are sent to PCP officeAHCP and discharge summary are sent to PCP office
• Patient reminded about post discharge phone callPatient reminded about post discharge phone call
• phone number for follow-up call confirmedphone number for follow-up call confirmed
RED Implementation – Strategies at time of discharge
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RED TEAM-based CARE
MD team RN team Case Mgmt Unit Coordinator/
Rounding Asst
Educate patient Confirm medication plan
Coordinate post discharge services
Arrange 7-10 days post discharge follow up visit
Discuss outstanding issues
Teach AHCP Review steps to take when problems arise
Prepare AHCP
Reconcile discharge plan with national guidelines
Assess degree of understanding –
Teach Back
Reinforce AHCP
24-48 hrs post- hospital discharge phone call
Transmit AHCP & discharge summary
24 hours post dc
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Barriers to High Quality Transitions
• “Heads on Beds” • Med reconciliation• Discharge summary• Hospital-PCP communication • Language and health literacy • Cognitive Issues• Plan delegated to interns
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Role of Senior Leadership
• Set the vision and the goal• Communicate Commitment
• Newsletter, grand rounds, M+M, RCA, emails• Provide resources & staff• Create implementation team• Set policies to integrate across organizational boundaries • Get IT on board • Hold people accountable• Recognize and reward success
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Role of Implementation Team
• Recruit a collaborative, interdisciplinary team• Identify process owners and change champions• Staff Engagement
• Energize staff • Get buy-in
• Implement a Plan that will work• Build skills to support and sustain improvement • Trouble shoot as RED is rolled out• Monitor progress to provide feedback
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Question for you…..
• What barriers or facilitators have you faced in helping to manage your hospital discharge process better?
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Conclusions
• Hospital DC is low hanging fruit • Changing the Culture of Hospitals is Hard• RED
• Can decreased hospital use • 30% overall reduction, NNT = 7.3• Saves $412 per patient
• Health IT has great potential• Team-based Efficiency key to
implementation• Determining who benefits is important
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QUESTIONS FOR ME??
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Project RED Website
http://www.bu.edu/fammed/projectred/
Thank You!
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Upcoming RARE Events….
Stay tuned for the next RARE Mental Health Webinar’s:
April 21, 2014 Care Transitions Interventions in Mental HealthHarold Pincus, Columbia University
May 19, 2014 In-REACH ProgramElizabeth Keck, Allina Health
June 26, 2014New York Office of Mental HealthDr. Molly Finnerty
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Future webinars…
To suggest future topics for this series, Reducing Avoidable Readmissions Effectively “RARE” Networking Webinars, contact:
Kathy Cummings, [email protected]
Jill Kemper, [email protected]