Testing the R e- E ngineered D ischarge

1. Testing theRe-Engineered Discharge Hands-On Health Literacy September 9, 2008 Principal Investigator: Brian Jack MD Associate Professor and Vice Chair Department of Family Medicine Boston Medical Center / Boston University School of Medicine

2. “Perfect Storm”of Patient Safety“ Loose Ends - workups NOT completed Communication - DC summary not available Poor Quality Info- DC summary lack results Poor Preparation- few pts know meds/dx Fragmentation- who is in charge?

3. Principles of the RED:Creating the Toolkit

4. RED Checklist Eleven mutually reinforcing components:  Medication Reconciliation  Reconcile Plan with National Guidelines  Follow-up Appointments  Outstanding Tests and Studies  Post-discharge Services  Written discharge plan  What to do if a problem arises  Patient Education  Assess patient understanding  Dc summary to PCP > Telephone Reinforcement Adopted by National Quality Forum as one of 30 "Safe Practices" (SP-11)

10. Intervention to Administer RED • In Hospital - Discharge Advocate (DA) • Nurse • Interact with care team – med rec and guidelines • Prepare the After Hospital Discharge Plan (AHCP) • Teach the AHCP • After Discharge – Clinical Pharmacist • Follow-up call @ 2-3 days • The DA and Pharm manual • Scripts for each task

11. Testing the RED Schematic RED Intervention 30 day Outcome Data Telephone Call Chart Review Enrollment N=750 Randomization Usual Care Informed Consent

12. AHCP Evaluation:30 days post-discharge How useful was the booklet to you? 4% 19% 17% 21% 39%

13. AHCP Evaluation:30 days post-discharge What was the most helpful part of the booklet? 15% 13% 15% 25% 12% 20%

14. AHCP Evaluation:30 days post-discharge How helpful was the RED medication calendar? 4% 9% 26% 15% 45%

15. Self-PerceivedReadiness for Discharge 30 days post-discharge

16. Primary Outcome

17. 1.0 0.8 Probability of survival 0.6 0.5 0 5 10 15 20 25 30 Days after Discharge Cumulative Hazard of Patients Experiencing an Hospital Utilization in 30d After Index Discharge ---- RED ---- Usual Care Chi-square p=0.005

18. Conclusions from the RCT RED: • Successfully delivered using • RED protocols • AHCP • Improves ‘Readiness for Discharge’ • Decreases hospital use • 32% reduction • NNT = 7.9 • Helps high hospital utilizers • 40% reduction • Is Cost-Effective • $329 / patient • 38 million discharges @ $753 billion x 32% eligible = 4 billion

19. Embodied Conversational Agent Teaches the AHCP Emulates face to face communication Develops therapeutic alliance Empathy Gaze, posture, gesture Competency Questions Can drill down in med education Maps of test sites and CHCs Instructions – e.g., Lovenox, Glucometer Workstation database Connects to hospital IT Prints AHCP “Feeds” Louise Concordancy Studies Kiosk for patient access Major Problem: RN TimeCan Health IT Help? Louise

21. Social Chat

22. Cover

23. Medications

24. Appointments

25. Diagnosis

26. Closing

27. Thank You AHRQ! • PI: Brian Jack, MD • Michael Paasche-Orlow MD, MPH • Caroline Hesko, MPH • Irina Kushnir • Fiana Gershengorina • Kim Visconti, RN • Jared Kutzin, RN, MPH • Alison Simas, RN • Mary Goodwin, RN • Lynn Schipelliti, RN • Lindsey Hollister • Maggie Jack • Kacie Fyrberg, RN • Vimal Jhaveri • Laura Pfeifer • Juan Fernandez • David Anthony, MD, MSc • Tim Bickmore PhD • Gail Burniske, PharmD • Kevin Casey, MPH • VK Chetty, PhD • Allyson Correia, RN • Larry Culpepper, MD, MPH • Shaula Forsythe, MPH, MS • Rob Friedman, MD • Jeffrey Greenwald, MD • Anna Johnson • Anand Kartha, MD • Christopher Manasseh, MD • Julie O’Donnell