Project RED The Re-Engineered Discharge

1. Project RED The Re-Engineered Discharge JCR’s AHRQ-funded Project April 2010

2. Disclaimer This presentation and slide set do not represent the policy of either the Agency for Healthcare Research and Quality (AHRQ) or the U.S. Department of Health and Human Services (DHHS). The views expressed herein are those of the presenter, and no official endorsement by AHRQ or DHHS is intended or should be inferred. Current information about the Patient Safety Program should be obtained from AHRQ, and not from these slides.

3. Deborah M. Nadzam, PhD Project Director, AHRQ KT/I Contract Joint Commission Resources Kim Visconti, RN Discharge Advocate Boston Medical Center Speakers

4. Today’s Web Conference • Objectives of AHRQ-funded Knowledge Transfer project - Deborah Nadzam • Project RED – 11 steps to an improved patient discharge process Kim Visconti • The value proposition of Project RED Deborah Nadzam • How to participate in this project Deborah Nadzam

5. AHRQ-funded Knowledge Transfer Project • Background • Knowledge Transfer/Implementation contract • Task assignment: Project RED intervention • Secure and support participation by 50 hospitals

6. Project Expectations • Secure executive sponsorship • Assign project team and project leader • Identify targeted population of patients* • Determine approach for generating After Hospital Care Plan (ACHP)* • Identify discharge advocate(s) and staff to make post-discharge phone calls • Participate in focus group conference call

7. Project Expectations cont’d • Participate in web conference training • Schedule bi-weekly consulting calls with assigned JCR consultant • Provide data to JCR re: readmission, ALOS, patient satisfaction, resource investments • Participate in all-site web conference discussions • Participate in case-study interviews

8. “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 marked with poor quality. • Loose Ends • Communication • Poor Quality Info • Poor Preparation • Fragmentation • Great Variability • 19% of patients have a post-discharge AE • 20% of Medicare patients readmitted within 30 days • Only half had a visit in the 30 days after discharge1

9. 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 • http://www.hospitalcompare.hhs.gov/

10. Most Common Reasons for Avoidable Readmission are not Diagnosis-specific Poor discharge instruction: Poor patient understanding of how to use medications Patient doesn’t learn warning signs to report to their physician Poor transfer of information to ambulatory caregivers: Hospital to nursing home staff Hospital to primary care physician Lack of clarity on end of life care preferences

11. Most Common Reasons for Avoidable Readmission cont’d Lack of timely post-discharge physician visit: Physician unaware of hospitalization Patient has no primary care physician Patient has no transportation to see primary care physician Poor medication reconciliation yields duplication or interaction

12. 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 follow up for heart failure patients Readmissions higher for heart failure patients with behavioral problems

13. Diagnosis-specific Reasons for Avoidable Readmissions cont’d Post surgery— Surgeons not arranging for post-surgical primary care. Post-CABG patients, expecting to be pain free, seek readmission for angina Inadequate teaching of the patient in caring for their body after surgery (e.g., incision care) Dialysis patients very vulnerable to drug therapy changes

14. Kimberly Visconti, RNDischarge AdvocateDepartment of Family Medicine Boston University Medical Center The ReEngineered Discharge Implementation Overview

15. 1) Explicit delineation of roles and responsibilities 2) Discharge process initiation upon admission 3) Patient education throughout hospitalization 4) 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 Principles of the Newly Re-Engineered Hospital Discharge

16. RED Checklist Eleven mutually reinforcing components: 1. Medication reconciliation 2. Reconcile discharge 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. Discharge summary sent to PCP 11. Telephone reinforcement Adopted by National Quality Forum as one of 30 US "Safe Practices" (SP-15)

17. RED Component #1Educate patient about their diagnosis throughout the hospital stay • The RED intervention starts within 24 hours of the patient’s admission to the hospital and continues daily until discharge • SP-15: “preparation for discharge occurring with documentation, throughout the hospitalization”

18. Schedule PCP appointment within 2 weeks after discharge Review the provider’s location, transportation and plan to get to appointment Consult with patient regarding best day and time for appointments Discuss reason for and importance of all follow-up appointments and testing RED Component #2 Make appointments for clinician follow-up and post-discharge testing • SP-15: “explicit delineation of roles and responsibilities in the discharge process”

19. RED Component #3 Discuss tests/studies completed and who will follow-up on results Explain tests and studies done while in the hospital and tell the patient which clinician is responsible for reviewing the results Encourage the patient to discuss tests his/her PCP; let the patient know that this information will be listed on the AHCP SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge”

20. Red Component #4Organize Post-discharge Services Collaborate with case manager and social worker about patient needs and post-discharge services Provide patient with contact information for these services (phone number, name of company, etc.)

21. RED Component #5Confirm the Medication Plan Reconcile the patient’s home medication list upon admission to the hospital Review each medication; make sure that the patient knows why they take it Discuss new medications each day with medical team and with patient SP-15 “completion of discharge plan and discharge summaries before discharge”

22. RED Component #6Reconcile discharge plan with National Guidelines Communicate with medical team each day about the discharge plan Recommend actions that should be taken for each patient under a given diagnosis

23. RED Component #7Review appropriate steps for what to do if a problem arises SP-15 “The time from discharge to the first appointment with the accepting physician represents a period of high risk. All patients discharged from hospitals should be told what to do if a question or problem arises, including whom to contact and how to contact them. Guidance should also be provided about resources for patients’ questions once they are discharged.” • What constitutes an emergency • What to do if a non-emergent problem arises • Where to find contact information for the • discharge advocate and PCP on the After • Hospital Care Plan

24. RED Component #8Expedite transmission of the discharge summary to the PCP Fax the discharge summary and AHCP to PCP within 24 hours after discharge SP-15 “reliable information from the primary care physician (PCP) or caregiver on admission, to the hospital caregivers, and back to the PCP, after discharge, using standardized communication methods” “A discharge summary must be provided to the ambulatory clinical provider who accepts the patient’s care after hospital discharge.”

25. RED Component #9 Assess degree of understanding by asking patient to explain the details of the plan Deliver information to reach those with low health literacy level Include caregivers when appropriate Utilize professional interpreters as needed SP-15 "Before discharge, present a clear explanation that the patient understands that addresses post-discharge medications, how to take them and how and where prescription can be filled.  This information must also be communicated to the accepting physician.”

26. RED Component #10 Give the patient a written discharge plan at time of discharge The AHCP should include: 1) Principal discharge diagnosis 2) Discharge medication instructions 3) Follow-up appointments with contact information 4) Pending test results 5) Tests that require follow up SP-15 “coordination and planning for follow-up appointments that the patient can keep and follow-up of tests and studies for which confirmed results are not available at time of discharge”

27. After Hospital Care Plan

36. RED Component # 11Provide telephone reinforcement of the discharge plan after discharge Call patient within 72 hours after discharge Assess patient status Review medication plan Review follow-up appointments Take appropriate actions to resolve problems SP-15 “Prospectively identify and provide a mechanism to contact patients with incomplete or complex discharge plans after discharge to assess the success of the discharge plan, address questions or issues that have arisen surrounding it, and reinforce its key components, in order to avoid post discharge adverse events and unnecessary re-hospitalizations" 

37. 11 RED Components Enable Discharge Advocates to: 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

38. Challenges to Implementation:Medical Team Related Busy medical team; discharge receives low priority in the work schedule of inpatient clinicians Discharge is relegated to least experienced team member Last minute test / consultations resulting in delay of final discharge plan and medication list Inaccurate medication reconciliation Discharge medication reconciliation started on the day of discharge

39. Challenges to Implementation:Hospital Related Lack of resources and financial incentives to sustain discharge programs Standardized discharge papers; not personalized or in language of patient Resistance to change by clinicians Financial pressure to fill beds as soon as they are empty 

40. Challenges to Implementation:Patient Related Patient with no PCP Limited or no insurance coverage Inability to pay for medication co-pays Long wait times calling health centers Late discharge; less effective teaching to patients who are anxious to leave

41. Using Health IT to Overcome Challenge of RN Time Potential in future to link to patient EMR so that information can flow into workstation Assist in transferring clinical information between health care settings Enhance patient education before discharge Develop therapeutic alliance with patients Help determine patient competency

42. Automated Discharge WorkflowSP-15 “the development of IT systems to collect discharge information and create discharge plans from existing hospital databases could enable components of the plan to be easily collected”

43. Conclusions RED is NQF Safe Practice RED: Can be delivered following the 11 components and using the ACHP tool Can decrease hospital use 30% overall reduction Savings of $412 per patient Success through elimination of barriers -- Coordination and change are challenging -- Providers must collaborate and work together Health IT could help Improve delivery Further improve cost savings and build the business case

44. Value Proposition Hospitals Improved HCAHPS scores Potential reduction in malpractice claims Prepared for changes to CMS reimbursement penalties for high readmission rates Improved relationship with private insurers looking to contain costs Improved nurse/provider time utilization Demonstrated “Meaningful Use” under the HITECH Act, eligibility for Medicare bonuses Improved relationship with PCPs

45. Value Proposition cont’d Insurers Direct cost savings from reduced hospital utilization ($412 per patient discharged) Patient satisfaction Improved long-term patient outcomes

46. Value Proposition cont’d Providers Improved nurse/provider time utilization Demonstrated “Meaningful Use” under the HITECH Act Additional revenue from Current Procedural Terminology (CPT) codes Improved patient satisfaction

47. Value Proposition cont’d Patients/Caregivers Improved outcomes Co-pays and premiums applied to more effective services Enhanced autonomy and ability to direct care Enhanced portability of personal health records

48. Value Proposition cont’d Primary Care Physicians/Other Specialists Improved utilization and show rates by patients Improved transmission of information to better care for patient Increased patient satisfaction

49. Ready for Project RED? • Next Steps • Secure leadership commitment • Identify targeted populations to begin • Determine approach for developing After Hospital Care Plan • Identify staff: Project Leader, Project Team, Discharge Advocate(s)

50. Identify Targeted Patient Population • Start small! • Approaches to consider • Specific patient care unit • Diagnostic group • Physician’s patient group • Combination of above • Also • English-speaking patients • Discharged home • Access to telephone