Jeff Greenwald, MD Co-Investigator, Project RED Co-Investigator, Project BOOST ACGIM December 8, 2008

1. Jeff Greenwald, MDCo-Investigator, Project REDCo-Investigator, Project BOOSTACGIMDecember 8, 2008

2. Overview: Project RED: Research in Progress Project BOOST: Furthering QI Education while Improving Transitions of Care

3. Factors influencing re-hospitalization

4. Principles of the Newly Re-Engineered Hospital Discharge Re-engineered Discharge must contain: Roles and responsibilities Patient education throughout Easy Information flow Full time case management services All discharge information in patient’s language and literacy level.

5. Principles of the Newly Re-Engineered Hospital Discharge Written discharge plan: Medications, diet, and lifestyle modifications follow-up care patient education re their disease what to do if their condition changes completed before discharge Post-discharge plan reinforcement Organized information delivered to the PCP Process measures, benchmarks, and QC

6. PIPS-RED:The current study

7. The InterventionGroup The intervention: The Discharge Advocate (D.A.) during admission After Hospital Care Plan A scripted follow-up phone call from a pharmacist 2-3 days after discharge Access to the D.A. by phone, after discharge

8. The Role of the DA Coordination with medical team, RNs, and Case Managers Educating patients about their disease Arranging aftercare with patient & family Reinforcing national quality guidelines Medication education & reconciliation Arrangements for medication pick-up, rides, DMA Preparing & reinforcing After Hospital Care Plan with patient & family Data collection tools are scripted for consistency REALM (literacy) Depression Screen (PHQ-9)

15. PharmD call highlights(2-3d post-discharge) MEs due to failure to take medication: (n=169)

16. MEs due to incorrect self-administration: (n=169) PharmD call highlights(2-3d post-discharge)

17. MEs due to system error: PharmD call highlights(2-3d post-discharge)

18. PharmD call highlights(2-3d post-discharge)

19. Primary Outcomes(Interim)

20. Conclusions RED: Decreases ED use (by 35%) Identifies a lot of medication errors Improves ‘Readiness for Discharge’* Helps limited health literacy patients* Successfully delivered using AHCP* Is Cost Effective*

22. John A Hartford Foundation grant to SHM Multidisciplinary advisory board Components: Workbook Website Toolkit Yearlong mentorship

23. Tools: TARGET: Tool for Addressing Risk – a Geriatric Evaluation for Transitions Risk assessment (7Ps) Risk specific intervention Universal Patient Discharge Checklist Raising the bar on all discharges GAP (General Assessment of Preparedness) Addresses psychosocial and logistical issues

24. Enrolled 6 pilot sites Recruiting NOW 24 additional sites for mentored implementation program Website: free to all – www.hospitalmedicine.org/BOOST QI skills building Mentorship for accepted sites free

25. Thank You!